A COMPENDIUM 



Principles and Practice of Medicine, 



USE OF STUDENTS AND PRACTITIONERS. 



STEPHEN H. POTTER, M. D., 

r 

EMERITUS PROFESSOR OF CLINICAL MEDICINE IN THE AMERICAN MEDICAL 
COLLEGE, ST. LOUIS, MO., ETC. 



SECOND EDITION- — REVISED AND ENLARGED. 



dj 

J..W 



HAMILTON, OHIO: 

BUTLER COUNTY DEMOCRAT PRINT. 

1879. 









Entered according to the Act of Congress, in the year 1878, 

BY STEPHEN T£ . POTTER, M. D., 

In the office of the Librarian of Congress. All rights reserved. 



1 J 



Preface to the Second Edition, 



Long personal experience, as to the wants of the busy practitioner, and 
the devoted student, convinces the author that a work of reference is 
indispensable. A compend, in a compact and tangible form containing 
the proper knowledge of a purely practical nature, is a desirable addition 
to any medical library. The active physician is often at a loss to know in 
what direction to look for such facts and suggestions as are here collected. 
Some are scattered through voluminous treatises, or in many instances 
are found only in the — to him — inaccessible pages of medical periodicals. 
The precepts and hints offered for guidance will, it is believed, supply 
often and urgent need. Students, in attempting to take notes, as all 
should, are hurried along the current of lectures, and often seize upon 
unimportant remarks, instead of the essential facts to be retained. Notes 
taken by different students often compare strangely; to them this compend 
will prove invaluable. 

The cordial endorsement of the first edition, the frequent, and urgent 
demand for a second one, by leading and active members of the profession 
— with which the author has been favored — inspire the hope that the 
present volume, in its revised and enlarged form, may become an indis- 
pensable companion to students and practitioners. 

In compiling this compend, the author takes great pleasure in gratefully 
acknowledging his obligations to the able and voluminous writings o f 
Tanner, King, Mint, Howe, Roberts, Scudder, Memeyer, Newton, Wood, 
Hartshorn, Dunglison, Ziemssen's Cyclopaedia of the Practice of Medi- 
cine, and the files of many different medical periodicals, etc. (This unpre- 
tentious volume is not intended to take the place of, or supersede any 
other. It is offered as a ready helper, when want of time will not permit a 
more extensive research. There is no easy road or short cut to sound 
medical attainments. S. H. POTTER. 



CONTENTS 



CHAPTER I. 

Preface to second edition 

Introductory explanations 5 

CHAPTER n. 

Causation of Disease. — Etioloy — General and Special 9 

CHAPTER HI. 

Anatomical Changes. — Congenital Malformations — Hypertrophy — Atro- 
phy — Induration — Softening 16 

CHAPTER IV. 

Symptomatology or Semeiology 22 

What We Must Know of a Patient 22 

How to Examine a Patient 23 

Rules for Practitioners 31 

SECTION II.— CHAPTER I. 

Hypersemia — Congestion. — Forms of— Post Mortem Appearances 33 

CHAPTER II. 

Dropsy — Hydropsy. — Varieties — Causes — General Treatment 37 

CHAPTER III. 

Hemorrhage. — Varieties — Sources — Prognosis — Hemorrhagic Diathesis 

— General Treatment 39 

CHAPTER IV. 

Inflammation. — Changes Observed — Varieties — Nature and Origin — 
Results and Products — Suppuration and kinds of Pus — Ulcera- 
tion — Gangrene or Mortification — Effects on Different Structures — 
Symptoms — Results— Treatment 41 



CONTENTS. 



CHAPTER V. 

Degenerations. — Fatty Metamorphosis. — Caseation or Cheesy Degenera- 
tion. — Causes and Effects. — Fatty Infiltration. — Mineral, Calcare- 
ous Degeneration. — Petrification. — Fibroid, Pigmentary, Mucoid, 
and Colloid Degenerations. — Lardaceous Disease. — Albuminoid 
Infiltrations. — Amyloid Degeneration. — Waxy Disease 54 

CHAPTER VI. 

Fever or Pyrexia. — Type due to the Course and Mode of Progress — Due 
to Combination and Severity of Symptoms. — Low Types of Fever. 
— Pathology — Increase of Temperature, Excessive Excretory 
Elimination, Deficient Elimination, Emaciation, Debility, and 
Prostration — General Treatment 64 

SECTION III. 

Classification of Diseases 75 

CHAPTER I. 

Contagion . — Origin — Source. — Conditions and Modes of Propagation. — 
How Transmitted. — How it Gains Access. — What Constitutes 
Infection. — Degree of Contagiousness. — Nature of Contagion — 
Chief Theories of. 77 

Epidemics. — Varieties: — Sporadic, Endemic, and Epidemic. — Prevention, 

and Limitation of Epidemics 82 

CHAPTER II. 

Clinical Investigation of Acute Febrile Diseases. — The Use of the Ther- 
mometer 88 " 

PART II. — Individual Diseases. 

CHAPTER I. 

Zymotic Diseases. — Variola — Small -pox — Varieties. — Varioloid.— Vac- 
cination. — Varicella. — Scarlatina — Varieties. — Diphtheria — Etiolo- 
gy, etc. — Measles. — Morbilli — Rubeola. — Mumps. — Parotitis Conta- 
giosa. — Whooping-cough. — Pertussus. — Influenza. — Epidemic 
Catarrh. — Dengue— -Break-bone Fever. — Malarial Fever. — Inter- 
mittent — Remittent — Typho-Malarial — Yellow— Cerebro-Spinal — 
Relapsing — Typhus — Typhoid Fever. — Cholera. — Epidemic — Asi- 
atic — etc 93 

CHAPTER II. 

Constitutional Diseases — Diathesis. — Rheumatism. — Varieties. — 
Gout. — Scurvy .—Constitutional Syphilis — Secondary — Syphiliza- 
tion — Infantile Syphilis. — Scrofula. — Rickets. — Anaemia. — Leu- 
cothyaemia — Pyaemia. — Embolism — Thrombosis. — Melasma — 
Supra-Renalis— Addison's Disease. , 169 



CONTENTS. Ill 

CHAPTER III. 

Diseases of the Digestive Organs. — Stomatitis. — Tonsillitis— Pharyn- 
gitis.— Retro-Pharyngeal— Abscess.— Stricture of the (Esophagus.— 
Gastritis.— Gastro-Hepatic Catarrh.— Chronic Gastritis.— Gastric 
Ulcer.— Induration of the Pylorus.— Dyspepsia.— Enteritis.— Peri- 
tonitis.— Colic— Varieties.— Obstruction of the Bowels.— Cholera 
Morbus.— Constipation.— Diarrhoea— Varieties.— Malsena.— Cholera 
Infantum.— Dysentery.— Diseases of the Caecum and Appendix 
Vermiforrnis 202 

CHAPTER IV. 

Diseases or the Liver and Its Appendages.— Jaundice. — Congestion. 
— Suppurative Inflammation.— Abscess.— Inflammation of the Bile- 
Ducts. — Chronic Diseases of the Liver 245 

CHAPTER V. 

Diseases of the Gall Bladder. — Gallstones. — General Diagnosis — 

Prognosis and Treatment of Chronic Diseases of the Liver 280 

CHAPTER VI. 

Diseases of the Spleen.— Pancreas.— Suprarenal Capsules. — Abdom- 
inal Aneurism 292 

CHAPTER VII. 

Diseases of the Urinary Organs. — Uraemia. — Nephritis. — Bright 's 

Disease. — Diabetes. — Cystitis... 309 

CHAPTER VIII. 

Diseases of the Respiratory Organs. — Pneumonia. — Pleurisy. — Ab- 
scess of the Lung. — Pulmonary Gangrene. — Emphysema of the 
Lung.— Collapse of.— Bronchitis.— Asthma —Bronchial Dilatation.— 
Laryngitis. — Laryngoscope. — Laryngismus. — Croup — Varieties. — 
Pleurodynia, — Phthisis Pulmonalis.— Cancer.— Rare Formations. — 
Haemoptysis 319 

CHAPTER IX. 

Diseases of the Circulatory Organs. — Angina Pectoris. — Syncope. — 
Palpitation.— Acute Pericarditis.— Endocarditis.— Acute Myocardi- 
tis. — Valvular Disease. — Hypertrophy. — Atrophy.— Fatty Degener- 
ation. — Modes of Sudden Death in Heart Disease. — Thyro-Cardiac 
Disease. — General Diagnosis — Prognosis and Treatment of Chronic 
Cardiac Diseases. — Rare Cardiac Diseases. — Malformations of the 
Heart and Great Vessels 355 

CHAPTER X. 
Diseases of the Bloodvessels. — Arteritis. — Thoracic Aneurisms.— 

Mediastinal Tumors 388 

CHAPTER XL 
Diseases of the Brain and Nervous System.— Inflammation of the 



IV CONTENTS. 

Brain — Varieties. — Tuberculous Meningitis. —Hydrocephalus.— 
Softening of the Brain. — Inflammation of the Spinal Marrow. — 
Apoplexy. — Aphasia. — Paralysis — Varieties.— Locomotor Ataxia. — 
Epilepsy.— Catalepsy.— Convulsions— Varieties.— Chorea. — Tetanus. 
— Hydrophobia. — Neuralgia — Varieties. — Delirium Tremens. — 
Hysteria. — Hypochondriasis 396 

CHAPTER XII. 

Diseases of the Skin. — Exanthemata — Erythema — Urticaria — Roseola 
Papulae — Lichen — Strophulus — Vesiculae — Eczema — Herpes — 
Bullae — Pemphigus — Rupia — Pustulae — Ecthyma — Impetigo — 
Squamae — Lepra — Psoriasis — Pityriasis — Icthyosis — Maculae — 
Ephelis — Vitiligo— Chloasma — Alopecia— Hypertrophic— Naevus — 
Clavus — Veryuca — El ephantiasis — Condylomata — Tubercula — 
Acne— Molluscum— Lupus— Frambaesia— Keloid— Haemorrhagiae — 
Neuroses — Prurigo — Anaesthesia — Neuralgia Cutis — Parasitica — 
Scabies — Army-Itch — Favus — Sycosis — Tinea — Chloasma — Plica 
Polonica — Syphilida 440 

CHAPTER Xni. 

Hemorrhages. — Varieties : — Active — Passive — Traumatic — Sympto- 
matic — Critical— Vicarious — Epistaxis — Haemoptysis — Pulmonary 
Haematemesis — Haematuria — Intestinal — Uterine 468 

CHAPTER XTV. 

Dropsical Affections. — Varieties : — (Edema — Anasarca — Hydroceph- 
alus— Hydrothorax— Hydropericardium— Ascites— Ovarian — Hy- 
dronephrosis—Hydrocele 474 

CHAPTER XV. 

Entozoa— Intestinal Worms.— Cestoid— Taenia Solium— Mediocanel- 
lata — Echinococcus — Bothriocephalus Latus — Cysticercus cellulosa 
— Echinococcus Hominis — Cysticercus — Trematode — Distoma 
Hepaticum— Ophthalmobium— Bilharzia Haematobia— Tetrastoma 
Renale — Nematoid — Acaris Lumbricoides — Tricocephalus Dis- 
par — Oxyuris Vermicularis — Sclerostoma Duodenale — Filaria 
Medinensis— Strongylus Gigas— Trichina Spiralis 478 

CHAPTER XVI. 

Pestts Bubonica— Bubo Plague— "Black Death." 486 

CHAPTER XVII. 

Inhalation and Atomization 490 

CHAPTER XVin. 

Hypodermic Medication 493 

CHAPTER XIX. 

Natural Therapeutics....,,. , , 495 



INTRODUCTION 



Medicine, in the broadest sense of the term, comprises all per- 
taining to the knowledge, prevention and cure of disease; properly 
including the conduct of physicians in treating disease. 

The Medical profession includes all who devote themselves to the 
study and practice of medicine, surgery, and obstetrics, either 
separately, or combined. In our Country most physicians are, of 
necessity, general practitioners. Surgery, and obstetrics, as separate 
branches, can be practiced only in large cities. The distinction of 
physician, surgeon, and obstetrician is purely conventional. The 
only license given, or degree conferred by our medical colleges and 
universities is that of Doctor of Medicine. 

Medicine, divided into the three departments named is natural, 
and has enhanced the knowledge and efficiency in each department. 
Further subdivisions have been found useful and convenient. These 
are known as Specialties. It is obviously difficult for one mind to 
grasp and retain the vast and increasing accumulation of medical 
knowledge. It is as obvious that the great principles of medicine 
should be understood by the specialist, or undue relative promi- 
nence will be given to what is not of paramount importance. 

Pathology is the study of disease as a province of scientific medi- 
cal knowledge. It has two important divisions termed Special and 
General Pathology . Diseases manifest particular forms, or species — 
individual diseases. The study of these constitute special pathol- 
ogy, A morbid condition which enters into a number of individu-. 
al diseases is termed fever. In this sense the study of fever, be- 
longs to general pathology; but the study of each form of fever is 
special pathology. Thus, the relation of General and Special pa- 
thology is analogous to the relation between general and special 
anatomy; the first describes the various tissues which compose the 
different bodily organs, and the other describes the particular 
organs formed of those tissues. The number of tissues is small 
compared with the number of organs, so the morbid conditions in- 
cluded in general pathology are few when compared with the large 
number of diseases belonging to special pathology. General and 



INTRODUCTION. 



special pathology bear similar relation to each other, as the terms 
Science and Art. The former treats of principles, the latter ap- 
plies those principles to the practical developement of art. "Science 
is knowledge reduced to principles ; art is knowledge reduced to 
practice" 

General Pathology admits of several subdivisions. 1. Nomen- 
clature, or naming diseases. The name of each disease should ex- 
press the morbid condition and its situation. This desideratum is 
not yet attained because the character of some is not fully known, 
and long use renders it difficult to change some others. Inflamma- 
tion, which enters into a large number of individual diseases, is ex- 
pressed by the suffix itis added to the anatomical name of the part 
affected. Thus, pneumonitis, bronchitis, pleuritis, peritonitis, etc. 
are names denoting the character of each 'disease referred to, and 
the particular structure inflamed. The suffix cea a transudation, or 
flux, occuring in a part where the transuded liquid escapes upon a 
mucous surface. Examples are bronchorrhoea, gastrorrhoea, cys- 
torrhcea, entorrhoea, etc. terms not yet sufficiently in vogue. 

The suffix rhagia expresses a flow of blood, or hemorrhage from a 
mucous surface, as metrorrhagia, gastrorrhagia (haemateinesis, en- 
terorrhagia (melaena,) bronchorrhagia (hemoptysis, in like manner 
terms which have not displaced others in common use. The suffix 
algia signifies a morbid condition, causing pain without inflamma- 
tion. Thus, neuralgia is a general term, expressing an affection of 
a nerve or nerves ; as gastralgia, enteralgia, pleuralgia, etc. express 
the character and seat of the affection. 

Words ending in cemia apply to morbid conditions of the blood as 
anaemia (impoverishment), uraemia (morbid accumulation of urea in 
the blood), septicaemia (putrid infection of the blood). 

Words ending in uria are applied to certain morbid conditions of 
the urine ; as albuminuria, and oxaluria. The prefix hydro denotes 
a dropsical disease of a part named ; hydrothorax, hydrocephalus, 
hydro-peritoneum, hydropericardium. And the prefix pneumo de- 
notes the presence of air in a part ; as pneumothorax, pneumoperi- 
cardium. Modern efforts to introduce names expressive of the 
character and seat of morbid conditionsjiave measurably succeeded- 
As our pathological knowledge increases our nomenclature can be 
perfected. 



INTKODUCTION. i 

Another subdivision of General Pathology relates to the appre. 
ciable morbid changes in the solids and fluids of the body ; termed 
morbid anatomy. Morbid changes not visable, or not yet ascer- 
tained by our present means of observation are termed functional, 
and are also called dynamic. Appreciable anatomical changes, either 
permanent or persisting are known as lesions. The study of the 
minute anatomy of the tissues by the aid of the microscope is called 
Histology ; and the term Morbid, or Pathological Histology is some- 
times used to designate that portion of morbid anatomy relating to 
abnormal changes which the microscope reveals. Anatomical 
changes, or lesions belong to general pathology, so far as they are 
common to a number of diseases. 

Lesions do not constitute, but are the result of disease. They are 
always due to previous morbid actions in which consist the local 
affection. Lesions are serious or otherwise in proportion to their 
character, their situation, and the extent of structural change in- 
volved. 

Etiology, another branch of general pathology, treats of the 
causes of disease. These are numerous and their character and 
mode of action, so far as known, are of great importance in treat- 
ing disease. 

Symptomatology or Semeiology , is the study of the great number 
and variety of phenomina or events called symptoms, which disease 
occasions, and is included in general pathology. 

Diagnosis is the discrimination of diseases from each other, and 
is only second in importance to their treatment. 

Prognosis is the prediction of the probable course and termina- 
tion of diseases. Both diagnosis and prognosis also belong to gen- 
eral- pathology. 

Hygeine or Prophalaxis is the study of the prevention of disease ; 
and is a branch of medical knowledge of the first importance. 
This belongs to both special and general pathology. 

General Therapeutics includes the general principles involved in 
the means and measures of treating maladies. 

Special Therapeutics, is the special means employed in the treat- 
ment of individual diseases. In a practical view, this is the most 
important, being, in fact, the great object, aim and end of both the 
principles and practice of medicine, 

Pathology has been aptly termed morbid physiology. Both are 



8 INTRODUCTION. 

parts of the science of life, or biology. Both are occupied with 
vital processes, action and properties. The only difference being 
that physiology investigates them in health, and pathology in con- 
dition of disease. This division is obviously arbitrary, but suffici- 
ently marked and appropriate. Every physiological discovery 
sheds new light upon pathology. 

Disease is a term very difficult to define. ChomePs defines dis- 
ease : "A notable disorder affecting more or less of the constituent 
parts of the living organism, as regards either their material constitu- 
tion or the exercise of 'their functions ." This definition is, perhaps as 
good as any other. It is easier to say what it is not than to tell 
what it really is. Probably no individual can be found who enjoys 
perfect health of every organ and function. The medical man is 
never called before the boundary is passed between health and 
disease. 

In presenting this Compend of Medicine the aim of the author 
is to give a truthful statement of pathological knowledge as it exists 
at the present time. The progress of pathalogical knowledge has 
produced within the past few years, a great change in the principles 
and practice of medicine. Of future progress no one can predict. 
When physiologists have succeeded in elucidating more fully the 
phenomena of life, then pathologist, following closely up will be 
better able to explain the phenomena of disease. 



CAUSES OF DISEASE, OR ETIOLOGY. 



CHAPTER II. 

CAUSATION OF DISEASE, OB ETIOLOGY. 

This subject is very important, and demands careful investiga- 
tion. Every effort must be made to ascertain what influences have 
contributed to produce the morbid condition present, in every case 
of disease. 

Different terms are employed to classify the causes of disease. 
The proximate or pathological cause is the actual condition of any part 
or organ which develops the symptoms present. Remote causes are 
divided into predisposing and exciting, some of the latter are called 
determining causes. 

Predisposing causes include those which render the system, an 
organ, or a part more liable to be affected by the exciting causes ; 
these are the immediate agents in the production of some morbid 
deviation of function or structure, which constitutes disease, Pre- 
disposition is a state favorable to the action of an exciting cause, and 
the individual in whom it exists is said to be predisposed. What 
may predispose at one time may excite at another, especially when 
there are several injurious influences, acting together, for a long 
time. A predisposing cause may render one organ more liable to 
disease than another, as the influence of age upon the seat of 
tubercle or cancer. 

The causes of disease given more in detail are conveniently 
classified into : 

1. Intrinsic, which depends upon the person, in whom they are 
inherent, or acquired. 

2. Extrinsic, are chiefly external influences, and accidental. 

1. Intrinsic, a. Age. — Many diseases are more likely to oc- 
cur at certain periods in life than at others ; some tend to attack 
various organs at different ages, or certain tissues of the same part. 
The nutrative and functional activity of the general system, or of 
special organs, are greater at one period of life than at another, 

2* 



10 CAUSES OF DISEASE OR ETIOLOGY. 

hence, the liability to local or general disease is greater. Changes 
of structure towards decay, often account for the predisposition due 
to age, as degeneration of, and a brittle state of the blood vessels? 
tending to apoplexy. The young and old are very liable to mala- 
dies incident to those extremes in life. 

b. Sex. — An average larger number of males die than females. 
Females are more prone to some disorders than males, and vice 
versa. Other affections are limited to either sex. This is due to the 
different conditions of special organs in the two sexes and on the 
functions peculiar to each sex ; on dissimilarity of occupation , 
habits and constitutional vigor ; also, on peculiarities of the nerv- 
ous system. Women are more sensitive and excitable than men, 
and hence, are more prone to nervous disorders, &c. 

c. Constitutional Condition. — State of Health, &c. — A Con- 
genital or an acquired state of debility predisposes to numerous 
diseases. 

The opposite condition of vigor and robustness increases the lia- 
bility to acute attacks. The state of the blood has great influence 
in producing disorders due to its watery state (anemic) ; or the 
opposite, too rich in quality (plethoric). 

Prior Diseases, especially of an acute form predispose to excite 
others, as various fevers, pertussus, lung troubles, syphilis, rheu- 
matism, &c. A neglected symptom, as cough may lead to involving 
the whole lung.' 

Habitual neglect in attending to certain functions, as daily defeca- 
tion disposes to serious results. The existence of structural changes, 
of a morbid nature often predispose to further lesions, and may ex- 
cite disease in other parts, as a calcified condition of arteries rend- 
ers them liable to rupture ; lung affections often excite diseases of 
the heart, and vice versa, or one disease of the heart or lung may 
excite another. Direct loss of blood ; excessive, or chronic dis- 
charges ; the sudden suppression of an habitual discharge, or of a 
chronic skin disease, and some local expression of a constitutional 
disease, as gout, &c. all these may predispose to injurious results. 

d. Temperament. — Some pathologists urge that temperaments 
predispose to special diseases respectively. Others oppose this view 
as of not much practical value. Few individuals can be found 
whose physical functions and organs are so nicely balanced, as not 
to be inclined to some special form of disease. Four temperaments 



CAUSES OF DISEASE, OR ETIOLOGY. 11 

are described, the sanguineous, lymphatic, billions, and nervous. Cer- 
tain constitutional peculiarities are termed temperaments. Space 
will not admit of a proper discussion of this question here. 

e. Idiosyncrasy. — Certain things affect some persons injurious- 
ly which do not influence others similarly, or at all-; such is the 
case with articles of food, as honey, fish, butter, mushrooms, &c, or 
remedies, as quinine, ipicac, iodide of potassium, &c. This indi- 
vidual peculiarity is called " Idiosyncrasy." This may predispose 
to some diseases. Practical importance attaches to this, and it 
should be specially regarded in directing the diet, and in prescrib- 
ing medicines. 

/. Hereditary Predispositions. — Those diseases which are 
transmissable from parent to offspring, as conceded, are : 

(i.) Certain blood, or constitutional diseases, as syphilis, Cancer, 

scrofula, tuberculosis, diabetes, gout, rheumatism. 
(».) Some diseases of the nervous system, as insanity, neuralgia, 

epilepsy, apoplexy, chorea, paralysis, and hypochondria, 
(iii.) Physical Deformities, as well as deficiencies in connection 

with special senses, as deafness, blindness, &c. 
(iv.) Early degenerations, either general or local, and which ap- 
pear in degeneration of the vessels, fatty changes of organs, 
premature grayness or baldness, loss of the elasticity of the 
skin, loss of teeth, &c. These may not be identical in dif- 
ferent generations. 

(v.) Some cutaneous affections, as lepra, psoriasis, etc. 
(w.) Asthma and emphysema. 
(vii.) Urinary calculus and gravel, 
(viii.) Haemorrhoids (?). 

The conditions in the parent and child may be dissimilar, merely 
related, as epilepsy in one, and insanity in the other. A vicious 
habit in the parent may lead to disease in the child, as intemper- 
ance may originate special nervous . maladies. Constitutional dis- 
ease in a parent may sometimes cause a delicate and feeble child. 

Transmitted disease may be congenital and develop in the foetus 
in utero, or it may be delayed until after birth, at some period, or 
lie dormant until developed by some "exciting cause' 1 . In some 
instances, it may pass one generation and appear in the succeeding 
one. This is termed "Atavism?'. 

Intermarriage intensifies hereditary maladies of the same char- 



12 CAUSES OF DISEASE, OR ETIOLOGY* 

acter, as consumption, also of those very young, or of unequal ages, 
and those of close blood relations. 

Gout and perhaps asthma, when inherited, sometimes develop at 
an unusual early age. Some whole families are prone to certain 
disorders, and to have them severely, as infectious fevers, &c. 

The family history is thus shown to be of vast importance. In- 
quiry must be made as to parents, brothers, sisters and children, 
grand parents, uncles, aunts and cousins. Direct inquiry into 
habitual state of health, particular diseases, at what ages death 
occured ; and other points which any case may suggest. 

g. Race. — The influence of race increases the liability to special 
maladies and greater immunity from others. The prevalence of 
some diseases among particular races may be accounted for by 
their places of abode, mode of living, and their habits. 

2. Extrinsic Causes. — Depending on Surrounding Meteor- 
ological AND OTHER CONDITIONS. 

(i.) Atmosphere. — The air we breathe influences the condition 
of health in numerous modes. It may be impure. 

Improper ventilation, the air containing a large amount of the 
products of respiration combustion, &c. "The air has suspended in 
it a large amount of atmospheric and aqueous, microscopic germs — 
living organisms. Gases may be mixed with it, such as emanations 
from decomposing vegetable and animal matters, in sewers, ces- 
pools, and from various factories. Suspended impurities, as dust? 
hair, wool, cotton, minute fragments of metals, unconsumed car- 
bon, arsenic, &c. Specific poisons are often transmitted through 
this vehicle. A due proportion of moisture, whether deficient or 
excessive, is vastly important. The electrical condition of, or the 
quantity of ozone in it has influence. Lastly, the degree of at- 
mospheric pressure affects the health, as is shown in the ascent of 
high mountains, or the result. Atmospheric influences act either 
as exciting or predisposing causes, and are prolific sources of nu- 
merous diseases. 

(it.) Temperature. — Excessive or long continued cold or heat, 
•general or local, tend to disease, as sunstroke, and the effects of in- 
tense Arctic cold. Sudden atmospheric extremes, and exposure to 
cold winds are often very injurious. Exposure to a draft of air 
when heated and perspiring, inducing a ''chill", changing wet 
clothes ; going from a warm atmosphere into a cold, damp cellar, or 
ice-house, &c, excite disease. 



CAUSES OF DISEASE, OK ETIOLOGY. 13 

(iii.) Amount of Light and Isolation. — When this is persist- 
ently deficient great injury results, as imprisonment in dungeons, 
working in mines, &c. The kind and amount of artificial light used 
may have important influence. 

(u\) Soil. — The breaking up of soil often gives bad results. 
The chief modes, in which soil exercises its influence, are : the 
amount of matters contained, subject to decomposition; by its 
degree of permeability to moisture ; its effect on the light and heat 
of the sun, whether reflective or absorptive ; its chemical composi- 
tion, affecting the composition of contiguous air and water. Marshy 
soil, at a certain temperature, is prolific of malaria. Clayey soils 
are moist and cold. Gravelly and sandy soils are healthy, except 
when they contain vegetable matter. Soils containing magnesia 
and lime are reputed to induce renal calculus and goiter. 

(r.) Sewerage. — Deleterious gases emanating from sewers ; de- 
composing organic matter, and certain specific agents they contain, 
are fruitful causes of disease. Drinking water often becomes con- 
taminated with leakage from sewers and becomes the exciting cause 
of certain maladies, as typhoid fever, &c. 

(6.) Causes due to Social Condition and individual Habits, 
and special accidental influences. 

(?".) Food. — This may be of improper quality, scant in quantity, 
either habitually or temporarily, inducing or enhancing disease in 
children, or at any age. Excessive food, or too rich, or indiges- 
tible. Irregularities in time of eating ; bolting food, and imperfect 
mastication, from whatever cause, entail great organic and func- 
tional evil. 

(u.) Dkink. — Intemperance in alcoholic stimulants is a pro- 
lific cause of disease, which demands special attention in investi- 
gating the cause of maladies. Spirits frequently taken, strong, or 
slightly diluted, on an empty stomach, is the worst. Compounds — 
much sold as spirits, beer, etc., contain very noxious adulterations- 
Water, as often drank, or the want of it is a fruitful source of dis- 
ease. Insufficient supplies for purposes of cleanliness, etc., entail 
serious results. Too much fluid taken with meals do great injury. 
Water often conveys morbific agents into the system, as poisonous 
metals, certain salts, noxious gases, the ova of worms, and other 
living organisms, organic matters, especially the excretions, decom- 
posing vegetable matters, and specific poisons. Excessive tea- 



II • CAUSES OF DISEASE, OR ETIOLOGY. 

drinking is injurious, as is often manifest. Adulterated or de- 
composed milk has often been proved to be the medium of convey- 
ing specific poisons into the system. 

(Hi.) Other habits, as excessive smoking; snuff-taking ; the use 
of narcotics, opium, etc., or excessive indulgence in hot condi- 
ments, are usually very injurious. 

(iv.) Clothing. — Insufficient clothing, or overclad, either only 
from time to time or habitually ; leaving the bosom and limbs too 
slightly clad; the chest too little protected, or the reverse, over- 
weighted with clothing, too tight, interrupting circulation — all 
these exert baneful influences. It is dangerous to allow wet clothes 
to dry upon the body, for obvious reasons. 

(v.) Want of cleanliness, personal or domestic, often excite dis- 
ease. So, also, with certain fabrics which irritate the skin ; or 
when dyed with poisonous ingredients, may injure the system. 

(vf) Amount of Labor and Exercise.' — Excessive, prolonged 
labor, or only at intervals, or the reverse — too little exercise, or 
none — a sedentary life, give bad results. Various occupations 
illustrate ins tances of hygenic errors. Sudden, severe effort may 
prove dangerous to chronic structural disease. 

(yii.) Mental Causes. — Excessive intellectual study and effort 
combined with deficient rest and sleep ; anxiety, worry ; all violent 
and depressing emotions, as sudden joy, grief, deep anxiety, or 
severe sudden fright. All these either predispose to or excite dis- 
eases, especially of the nervous system. 

(viii.) Mechanical Causes. — These comprise a very important 
class, especially exciting or determining some morbid state, due to 
the direct irritation or injury which they produce. They are ex- 
ternal violence, chronic pressure, straining and over-exertion, the 
irritation of foreign bodies, and the long maintainance of a certain 
position, as accumulations of foeces, calculi, parasitic, animals and 
plants, and small particles of substances inhaled into the respira- 
tory organs. Occupations often prove injurious in some of these 
ways. A mechanical cause often excites a local expression of a 
constitutional malady ; as pressure, or injury, may develop cancer 
in an organ or part. 

(ix.) Venereal excesses, masturbation, too early, or frequent 
sensual excitement, are prolific causes of both functional and con- 
stitutional evil. 



CAUSES OF DISEASE, OR ETIOLOGY* 15 

The causes which have been noticed are generally more or less 
combined in any individual case. To ascertain which of them are 
acting, we inquire of a patient as to his residence, occupation, 
social condition, habits, previous health, and that of his family. 

4. Some diseased conditions are caused by the presence of 
poison in the blood which is generated in the body, resulting from 
perversion of digestion, assimulation and nutrition. Gout and 
other maladies, when once developed, may be transmitted. 
SPECIAL CA USES OF DISEASE. 

There are certain agents which cause it, yet to be considered, re- 
quiring special notice. They are mostly of the nature of various 
kinds of poisons, and give results which are more or less constant 
and definite. 

1. Chemical Poisonous Substances, Especially Metals. — Some of 
these act injuriously upon the system as the result of occupation, 
such as lead, mercury, arsenic, phosphorus, copper, gold, and other 
substances. Arsenic may be given off in the form of a fine powder^ 
from certain green papers used in papering rooms, and then be 
taken from the atmosphere by individuals. There are many other 
ways these metals may affect the system without being directly ad- 
ministered as poisons or medicines. 

2. Causes Originating in the Vegetable Kingdom. — Many com- 
mon poisons are derived from this source, such as opium, etc. 
Parasitic plants, growing in various structures of the body, are fre- 
quent causes of disease. This is marked in skin affections. The 
presence of certain fungi in the stomach is said to excite emesis 
etc. Decomposing vegetable matter often does great harm, causing 
malarial or miasmatic fevers, as ague, yellow fever, etc., and also 
some nervous and other complaints. 

Contagion is believed by many to be due to low vegetable 
organisms. 

3. Causes Originating in the Animal Kingdom. — Certain ani- 
mals are venomous and can inflict poisoned wounds, as serpents, 
etc. Some are poisonous when taken, as cantharides. Animal 
parasites set up morbid conditions, as worms, and those which 
infest the skin. Specific contagious poisons, as those inducing 
small-pox, scarlatina, etc. 

Casuality represents the last and essential point to be reached. 
The scientific rule for the classification of diseases must refer to 



16 

the cause, i. e., must be etiological. Then shall we learn how to 
deal with the root of maladies. The indicatio casualis will assume 
a high position in therapeutics, and we shall find efficient remedies 
with which to answer it. In many diseases a successful prdphalaxis 
will narrow therapeutics rendering much of the present superflu- 
ous. The science of public hygiene is based upon the etilogical 
principle, and is so firmly rooted in it that they cannot be separated- 
We are very far from having a complete etilogical classification^ 
because our present knowledge of the causes of disease, which have 
only very recently been subjected to a systematic investigation, 
is yet confined to the first rudiments. The unities of disease are 
yet mostly anatomical ; in fact, in many departments, we have not 
even reached this point, but are still obliged to recognize symptom- 
atic unities. Hence, we yet have such diseases as epilepsy, dia- 
betes, neuralgia, mental diseases, etc., expressive of neither the 
morbid condition nor the situation of many diseases in our present 
nomenclature. 



CHAPTER III. 



Anatomical Changes — Hypertrophy — Atrophy. 

Congenital Malformations consist of the malposition, the incom- 
pleteness, or absence of organs, either in redundency or deficiency 
of size ; deviations in form, supernumerary parts, want of proper 
connection of parts, etc. These may be caused by intrinsic defects 
of the ovum, to arrested or obstructed development, or by ex- 
trinsic causes and in some cases by diseases to which the foetus is 
liable. This subject more properly belongs to obstetrics, and will 
be considered no further here. 

Anatomical changes in solid parts are known by morbid appear- 
ances, some are obvious to the unaided eye, others require the aid 
of the microscope to detect them. Changes in color, form, etc 
seen by the naked eye are termed the gross appearances of disease. 
Those developed by the microscope are called microscopical charac 



HYPERTPOPHY — ATROPHY. 17 

ters. The touch determines certain changes, as density, roughness, 
smoothness, altered form, etc. Diminution and increase in weight 
must be noticed. The student must first become familiar with the 
normal appearances, gross and microscopal of the various organs and 
structures before he can be qualified to appreciate the changes re- 
sulting from disease. 

Anatomical lesions are : 1st. Lesions of quantity ; 2d. Lesions 
of consistence ; 3d. Lesions of composition. Those of quantity are 
first, a morbid increase, second, a morbid diminution of substances 
proper to the affected part. The abnormal change in this class is 
purely quantitative, not qualitative. A morbid increase of sub- 
stance is termed hypertrophy, while a morbid diminution of sub- 
stance is named atrophy. 

HYPERTROPHY. 
Hypertrophy — Hyperplasia — is an abnormal activity of nutri- 
tion, and enlargement by increase of the normal materials of the 
parts, without other change. It consists in an excess of appropria- 
tion. When a part enlarges from a deposit of material foreign to 
its normal composition, or from a disproportionate excess of certain 
of its normal constituents, the term false hypertrophy is applied. 
True hypertrophy simply consists in excess of nutrition. False 
hypertrophy is a perversion of this process, as when the liver is 
augmented by fatty deposit, carcinoma, etc. 

Hyper-nutrition is not always the cause of the enlargement of an 
organ. The hollow viscera as heart, stomach, bladder, etc., may 
increase in volume from dilatation, not by incrtase of substance, 
which perhaps is less than normal ; such is not hypertrophy. 

A physiological mystery yet exists as to why the body gradually de- 
velops to manhood, the inherent limit of size, preserving that 
definite size and form, during molecular changes incident to 
nutrition. 

True hypertrophy proceeds from prolonged excessive increase of 
the function/of a part. The heart is most liable to this lesion. 
The enlargement is generally due to valvular lesions, which, inter- 
fering with the passage of blood through the heart, induce perma- 
nently an increase of its muscular motion. This process increases 
the muscular walls in bulk, by growth, precisely as the voluntary 
muscles enlarge w T hen constantly exercised. The heart may en- 
large to six times its normal size, yet there is a limit to this pro- 
3* 



IS HYPERTROPHY — ATROPHY. 

cess. The necessity ceases after reaching a certain point, which 
varies in different individuals. Hypertrophy of the muscular 
tunic of the bladder, due to chronic urethral obstruction, illustrates 
this lesion, resulting from prolonged increase of function. Hyper- 
trophy of involuntary muscular structure involves the production 
of new fibres, as, during gestation, there is a development of the 
muscular uterine walls. 

If the function of one kidney is impaired, lost, or the kidney 
removed, hypertrophy of the other usually ensues. This is caused 
by doubling the functional activity and capacity of the other kid- 
ney. This is a conservative lesion of increased capacity for the 
bodily welfare. This is true of most lesions of hypertrophy in the 
muscular and glandular structure. Either undue determination 
of blood to a part, or inflammation may produce hypertrophy of 
fibrous and areoler tissues. Corpulence, or hypertrophy of the 
adipose tissue is a general diathesis of which the undue growth of 
the tissue is the expression. 

Hyperplasia is a term applied when new anatomical elements are 
generated, without other change than number, as in* increase of 
fibrilla in a muscle. 

ATROPHY. 

Atrophy — This is the reverse of hypertrophy ; the destructive 
assimulation continues, while fresh supplies are diminished, or sus- 
pended ; hence, loss of the proper substance being appropriated 
to a part, it undergoes waste. Atrophy may be general, in- 
volving all the tissues and fluids, but some more than others, 
as in old age, phthisis, cancer, etc. It may be limited to the 
muscular or glandular structures, only one organ, a special tis- 
sue in it, as the heart, liver, or kidney ; while other tissues 
may increase. 

Effects. — The weight diminishes, unless obscured by conges- 
tion, or in some other manner. Usually there is a lessening 
in size, not invariably ; sometimes there may be apparent en- 
largement. Atrophied parts are generally paler, and either 
dryer and firmer, or softer than normal. Their functions are 
impaired. 

Causes. — 1, Interference with the nutrative qualities of the 
blood causes general wasting ; deficiency in the quantity or 
quality of food ; diseases which disturb digestion and absorp- 



HYPERTROPHY ATROPHY. 19 

tion, also a direct loss of blood, and affections which remove 
the nutrative 'elements of the blood, as Bright's disease, pro- 
longed suppuration, or phthisis, cancer, etc., often involving 
the internal organs. 

2. Combined with the above causes, or alone, there is often 
an increased icaste of tissue, which cannot be repaired, as in 
fevers and other diseases. In some cases this is limited to a 
single organ, without apparent cause, as acute atrophy of the 
liver, etc. 

3. The general vitality and nutrative activity of the tissues may 
be impaired, or that of a special part or organ, and general or 
local atrophy result, as in u senile atrophy" and in the wasting 
of organs and structures at a period in life when functional 
activity ends, as in the thymus gland, spleen and lymphatic 
glands at different ages, and the rapid diminution of the uterus 
after delivery. Some previous disease may impair vitality, as 
inflammation, overuse, or deficient exercise have similar results, 
a s the brain or testicle. Opposite examples are common, as 
wasting of the muscles of paralyzed limbs, of bone after ampu- 
tation, or nerves after severing their connection with the cere- 
brospinal axis. 

4. A deficient supply of arterial blood will cause atrophy, 
whether interference with its passage to a part, or overload- 
ing the veins in continued mechanical congestion, producing 
mainly '-local atrophy." It may affect any part when the 
supply of blood is inadequate. If entirely stopped, gangrene 
results. 

5. Direct pressure upon an organ, as by pericardal thicken- 
ing on the heart leads to atrophy, the wasting of bone and 
other tissues, by the pressure of a tumor or aneurism, partly, 
not wholly, interfering with the supply of blood. 

6. Nerves influence nutrition ; when any nerve is paralyzed, 
atrophy is liable to occur in any part supplied with it. This 
is attributable to cessation of function, want of supply of blood, 
and the control of nerves over nutrition. 

7. Certain medicines, long continued, have power to cause the 
absorption of organs or tissues and atrophy, as mercury, iodide 
or bromide of potassium, alkalies, etc. This power is made 
use of to promote the removal of morbid products. 



20 INDURATION. 

8. Lastly, To account for "progressive muscular atrophy, 1 ' 
no adequate explanation has been reached. 
INDURATION. 
Induration — Expresses the condition of a part when its dens- 
ity and firmness is abnormally increased. In cirrhosis of the 
liver, the morbid production of fibroid material in the interlob- 
ular spaces gives to the liver an abnormal density and firm- 
ness. It is a change of the composition of the structure in- 
volving morbid products in the parts affected. Of that vari- 
ety of degeneration of the kidney characterized by contraction 
and hardness, the same is true. Induration occurs when parts 
are condensed by pressure, and when deprived of their normal 
quantity of liquid, as in pleuritis with large effusion In these 
cases the carnified lung is compressed into a small, compact 
mass resembling flesh, more than lung tissue, hence it is said 
to be carnified, though the composition and structure are not 
essentially altered. Insufflation after death restores the con- 
densed lung to its normal state, and this may be done in life 
if the liquid effusion is absorbed, or evacuated, and the pres- 
sure relieved. In lobular pneumonia a similar condensation of 
the pulmonary lobules occurs from collapse. 

Induration from deficiency of liquid is seen by the abnor- 
mal density and firmness of the brain, and other organs ; and after 
death from cholera, caused by intestinal transudation. Indur- 
ation of the substance of the brain has been observed in cases 
of acute and chronic lead poisoning ; and the brain in these 
cases has been known to contain sulphate of lead. Sclerosis 
(hard) is a term often used to denote induration. 

SOFTENING. 

Softening applies to a part when its density and firmness 
are abnormally diminished in a less or greater degree. Soft- 
ening is incidental to. some manifest change of composition or 
structure, or an element of certain morbid action, as inflamma- 
tion and gangrene; as an inflammatory deposit in pneumonitis, 
in the second stage. The affected part of the lung, though 
solidified (hepatized), has less firmness than normal, is said 
to be friable. This friability is marked in the stage of purulent 
nfiltration, the substance gives way under slight pressure. 

Softening constitutes a lesion of itself in cases in which por- 



SOFTENING. 21 

tions of the brain and spinal cord, have been found softened 
without previous inflammation. Non inflammatory softening of 
the brain is associated with degenerative changes of the coats 
of the cerebral arteries; the circulation is impeded and nutri- 
tion impaired ; it occurs from arterial obstruction, caused by 
a mass of fibrin or a vegetation derived from the left side of 
the heart, constituting an embolus or plug, as in certain cases 
of apoplexy. 

Softening is incidental to inflammation affecting any of the 
tissues. This is marked in inflammation of the mucous mem 
branes; they are often disorganized and reduced to a pulp, 
and removed by substances passing over them, as in dysentary, 
etc. Softening of the brain and spinal cord results from in- 
flammation extending from the meninges, developed around a 
clot of blood, or a tumor of some kind, or originating spon- 
taneously within the nerve centres. This subject will be more 
fully discussed in connection with some individual diseases. 

Softening which is non-inflammatory, independent of other 
palpable changes, is generally due to defective nutrition in the 
affected parts, as when cerebral softening is caused by arterial 
obstruction. It may be due to a deficiency of nutrative sup- 
plies in the blood, as softening of the heart in typhus or 
typhoid fever. 

Softening, consisting in merely a diminished coherence of 
the elements of the parts, without disorganization, is not a 
grave lesion. Softening of the brain, due to a temporary 
defect in the arterial supply, may lecover after the circulation 
is re-established. When softening involves disorganization, 
due to mortification and death of the affected parts, this has 
been called necrobiosis. This subject will be continued in con- 
nection with other topics, so far as it legitimately belongs to 
the practice of medicine, as distinguished from surgery. Per- 
versions of structure, abnormal products, infiltrations, exuda- 
tions, formations of tubercle, scrofula, carcinoma, etc., will be 
carefully considered hereafter. 



22 



CHAPTER IV. 



Symptomatology, or Semeiology. 

Symptoms express all the evidence of diseased condition in the 
living body. The name " symptom " signifies to fall together, 
and means concurrence of events. The terms associated with 
symptoms are : 

1. General or constitutional, and local, as either expressed by 
the whole body, or any special part of it. 

2. Objective and Subjective. — The first embraces all symptoms 
obvious to the senses of the examiner; the last those felt only 
by the patient. 

3. Direct, or Idiopathic, and Indirect. — The former denotes 
symptoms expressed by the diseased part ; the latter by some 
part remote, sometimes called sympathetic, as vomiting, occuring 
during pregnancy. 

4. Premonitory, or Precursory — Are symptoms indicating what 
is likely to occur, or giving warning of a disease. 

5. Diagnostic, Prognostic, and Therapeutic symptoms respective- 
ly indicate the kind of a disease, the prospect and the proper 
treatment. 

6. Pathognomic symptoms are the expressions of special dis- 
eases, and no other — absolutely belong to it. 

"i Sign'' 3 is a term which is expressive of the nature of the 
disease ; it is a diagnostic or pathognomic symptom. 

Physical signs are merely objective symptoms, only elicited by 
special modes of " physical examination." 

WHAT WE MUST KNOW OF A PATIENT 

How to Examine a Patient. — This should be conducted in a 
careful and systematic inquiry as to the condition of each organ 
so far as possible. In ordinary practice this is often impractic- 
able, and although desirable, the rule is not enforced. The 
following suggestions may give a plain and practical mode of 
examination : 



SYMPTOMATOLOGY, OR SEMEIOLOGY. 2$ 

The young practitioner will find it useful to him to take 
notes of his cases. These should be based upon a general sys- 
tem of inquiry, and comprise an outline sketch of each case 
from its inception to the termination, whether favorable or 
otherwise. This sketch can be filled up afterward when leisure 
affords the time. Such a table will prove useful to the most 
systematic of long experience. Dr. H. W. Acland's table 
is valuable for present and future reference, and it is here given. 

History. — When were you last well ? How did you first feel 
unvrell? Your supposed cause, mode of becoming sick, and 
have you had any treatment? 

Of what do you now complain ? Have you been sick before, 
and with what? If the foregoing, suggests it, inquire as to 
residence, occupation, past life, any change of habits, history of 
family, hereditary predisposition, etc. 

I. Present State. — General Aspect. — Manner, posture, color, 
shape, temperature, weight, eruption, oedma. Notice generally 
the head, neck, chest, abdomen, limbs. 

II. Organs of Digestion. — Taste, thirst, hunger. Lips : 
their color and texture. Teeth : Loose or diseased. Gums : Size, 
color, position, and texture. Tongue: Form, volume, color, 
surface, dryness, coating and protrusion. Stomach : Nausea, 
vomiting, eructations, pyrosis, pain while or before, or after 
eating, and how soon. 

III. Organs of Absorption. — Lymphatics : Tender, red, hard. 
Glands : Tender, swollen ; if so how long ? 

The patient must either be in bed, or undressed, for a further 
thorough inquiry into Nos. IV., V., and VI. 

IY. Examination of Abdomen- — Percussions, palpitation, 
measurement. Size of spleen and liver. Existence of pain, 
diminished or increased by pressure ; circumscribed or general ; 
under the hand or elsewhere. Existeuce of tumors, fluids, 
flatus, feces ; of hernia ; ot tumors in groin ; of hemorrhoids ; 
of feces in rectum. 

Y. Organs of Circulation. --Heart— Position, dimensions, 
force, rhythm, sound — its character, situation and distance. 
Arteries — Pulse at the wrist; rate, volume, hardness, laboring, 

egularity, intermission, dicrotism, etc ; murmurs. 

VI. Organs of Eespiration. — Respiration Generally : Fre- 



24 SYMPTOMATOLOGY, OK SEMeIOLOGY. 

quency, regularity, difficulty, odor of breath. Nares : Discharges, 
odor, action. Epiglottis; Larynx: Tenderness, alteration of voice. 
Cough : Its character and supposed cause. Expectoration : Color ? 
odor, tenacity, chemical, microscopical properties. 

Examination of Thorax - -Form flattened, round, symmetrical: 
supra- and infra-clavicular spaces, etc Movements: Vocal frem- 
ities ; intercostal spaces. Resonance on Percussion: Changed by 
posture. Sounds on inspiration, expiration, speaking, coughing 
succussion. 

VII. Organs of Secretion and Excretion. — Shin : Erup- 
tion ; sweat: quantity, chemical quality; locality. Kidneys: Pain 
in micturition ; its seat and direction ; pain in the loins. Urine : 
Frequency (night or day), .quantity, examination — acidity, spe- 
cific gravity, albun^en, sugar, bile, excess of urea, etc. 

Bladder: Tumors, irritability, etc., calculus. 

Bowels : Frequency of action, character of evacuations. 

VIII. Organs of Generation. — (Male,) penis, scrotum, tes- 
tes, cord. 

(Female,) Catamenia : Color, quantity, frequency, duration. 
Leucorrhcea, or other discharges. 
Pain : Its seat, duration, causes, periodicity. 
Uterine: Pelvic, ovarian enlargement, tenderness, ulcerations. 
External Sores: Eczema, pruitirs. 

IX. Nervous System. — Brain : General intelligence, mem- 
ory, speech, slowness of manner, headache (where), giddiness, 
sleep, dreams, fits, (one kind or more). 

Spinal Cord and Nerves : Pain, alterations, in kind or degree 
of sensibility, in sight ( pupils ), hearing, smell, taste, touch, 
numbness ; tremors, rigidity, rigors, paralysis. 

X. Organs of Motion. — Pain, stiffness, swellings, nodes, 
abscesses. 

The foregoing is what we should know of the patient aided by 
inquiry of friends, etc. A skillful and experienced practitioner 
can learn the truth of any case in order, or in no particular 
order The table is more especially given to train students 
and beginners, in the diseases to which each system of or- 
gans is liable, and to indicate the various symptoms peculiar 
to each disease, respectively 

Physical examination includes all modes of investigation by 



SYMPTOMATOLOGY, OR SIJMEIOLOGt. 25 



which objective symptoms can be made apparent. Special meth- 
ods of examination are limited, by many, to particular portions 
of the body, as the chest or abdomen. A general survey of 
the entire system is often required to make out the real nature 
of the disease. We must employ our external senses, aided by 
the use of various instruments, and by chemical and micro- 
scopic investigation. 

The symptoms which are connected with each individual or- 
gan or part, will be enumerated in describing each particular 
disease. It may be well to state here that pain is quite common 
to all maladies. This symptom is very liable to exaggeration, 
and may be merely sympathetic. The inquiries about the 
character of pain are : a. Is it acute, or chronic ? b. Its 
precise situation and extent, and structure in which it appar- 
ently exists? c. Its intensity and special character? d. Wheth- 
er it is constant or occasional, remittent, intermittent, or par- 
oxysmal? e. The effects of pressure upon it, whether showing 
tenderness or aflording relief, f. How it is affected by move- 
ment, as coughing, vomiting, eating, etc.; these vary with the 
structure in which the pain originates, and is often valuable 
in diagnosis. 

Mode of Invasion, Course and Duration of a Disease. — These are 
very important. The various points are: 1. The attack may 
be sudden, as apoplexy, syncope, many hemmorrhages, etc. 
The after course differing essentially according to its nature, 
often rapidly fatal. 2. Frequently it is acute, coming rapidly 
though often preceded by premonitory symptoms; being severe 
in its character, and brief in duration. Many acute maladies 
run a pretty definite course, as a rule, as pneumonia, or the 
eruptive fevers, and an acquaintance with their natural history 
is important. Irregularities are quite common, due to disturbing 
influences. In many diseases there are distinct varieties. When 
the onset is less rapid, and the symptoms milder, the case is 
termed sub-acute. 3. The majority of diseases are chronic, the 
symptoms milder and gradual, not severe, the progress slow 
and protracted. A chronic disease may be the sequel of an 
acute one, or acute may terminate in chronic. 

4. Some diseases have periodical exacerbations, coming on 

at regular or irregular intervals, the patient being compara- 

4* 



26 SYMPTOMATOLOGY, OH SEMEIOLOGY* 

lively, or quite, well, in the intervals. Such maladies are 
chronic in their progress, but acute in onset and intensity ? 
having an intermittent course, as ague, epilepsy, asthma, etc. 

Complications and Sequelae. — These are the advents of other 
affections, either during the course of the primary diseases or 
subsequent to their termination, or resulting from them. They 
are quite common in acute diseases, as fevers, etc. Compara_ 
tively, few primary acute diseases have a fatal termination. 
The setting in or development of some other disease during 
their course, or resulting from them, constitute the chief danger. 
The skillful practitioner guards carefully against complications and 
sequelw. 

Terminations. — Clinically considered, a case may terminate : 
1. In complete recovery, which may be .rapid and sudden ; usually 
gradual, the patient passing a period of convalescence, of less or 
greater duration. 

2. Incomplete Recovery. — Either general ill health remaining, or 
some part or organ being permanently altered in function or 
structure ; a more or less chronic state of disease remaining. 

3. Death. — This may occur suddenly, rapidly, or gradually. 
Death is a complex process, all the functions of the vital or- 
gans being more or less involved; often the heart, respiratory or- 
gans, or brain give signs of approaching dissolution. Death 
beginning at the heart is said to be by syncope, due either to a 
want of a proper supply of blood, produced rapidly or grad- 
ually (ancemia) or to a loss of contractile force due to me- 
chanical interference, structural changes, or disturbance of 
nerve function (cesthenia). In starvation these two modes of 
death are combined. Death, beginning at the lungs occurs 
by suffocation, or asphixia. This may be due to the inspired 
air being unfit to areate the blood, or not entering the lungs 
in sufficient quantity (apnoea), or a stoppage of the flow through 
them, as a clot suddenly obstructing the pulmonary arteries. 

Death, beginning at the brain, is said to be by coma, indi- 
cated by stupor or insensibility, soon followed by interference 
with the functions of respiration. The symptoms which indi- 
cate approaching death will be given when treating of the indi- 
vidual diseases of the various organs. 



SYMPTOMATOLOGY, OR SEMEIOLOGY- 27 

Diagnosis. — It is a primary object to arrive at a correct diagnosis 
in every case ; otherwise no rational treatment can be pursued* 
and it will be impossible to give correct prognosis. In making a 
diagnosis it is necessary to consider : 

1. Is there any disease in the patient ? Not a few call a 
physician and complain without cause, especially among the class 
of "malingerers.'' Others feign sickness to avoid, to them, 
unpleasant duties, etc. 

2. If there is any morbid condition present, is it of an acute 
or chronic character? 3. Does it affect the general system, or 
is it localized in any special organ or organs ? 4. If general* 
what is its nature? 5. If seated in some organ, is this merely 
disturbed in its functions, or is there organic and structural 
changes ? 6. If the latter, it is necessary to ascertain the nature 
of the structural alteration, the part and extent of the organ 
involved, and the stage of the disease, as in phthisis, whether 
tubercular or not ; how much of the lung or lungs are involved ; 
or, if there is merely consolidation, or if this has broken down 
into cavities ? 

The available points in aid of a correct diagnosis are : 1 
Patient's previous history, and his family history. 2. History of 
existing illness, duration, cause, and manner of attack. 3. The 
actual symptoms present, especially objective ones. 4. The 
progress, duration, and termination of the case 5. The result s 
of treatment. 

A Diagnosis is a process of reasoning, and the degree of 
difficulty varies much in different cases. In some cases a 
correct conclusion is readily reached from one or more "pathog- 
nomonic " symptoms ; in others every point must be carefully 
weighed, especially when diseases are similar, even then we 
may hesitate until after carefully watching the course of the 
case, and the effects of treatment until doubts and difficulties 
clear away. 

In some cases a diagnosis can only be made by exclusion, and 
occasionally it can not be made at all. 

One symptom is sometimes so marked, that the diagnosis 
consists in finding out the cause of it, as jaundice or ascites, 
etc. Usually if one organ is affected others may be also, and 



28 Symptomatology, or Semeiology. 

that diseases present several varieties; all these facts must be 
observed in making out the entire diagnosis. 

Prognosis. — To "give a prognosis" implies a knowledge of 
the nature, natural history, course, duration, complications, 
and termination of the disease considered; and an acquaint- 
ance which the influence of age, constitution, etc., have upon 
it; also those due to external influences. A positive opinion 
may be readily formed in many cases; if enshrouded in doubt, 
great care is requisite. Friends should be informed as to pos- 
sible danger, and probable favorable results. If uncertain, it 
is wiser to encourage, and persevere in treatment. Should 
both patient and friends lose hope, that would be the end 
of effort. 

The points at issue in regard to prognosis are : 1. Is the 
case likely to recover, or terminate in death? 2. Its proba- 
ble duration, in either event, and whether it may be sudden- 
3. If recovery: will it be complete, or will a morbid condition 
remain, especially organic? 4. When certain slight symptoms 
xist, are there signs of something more serious about to occur, 
as numbness or limited paralysis? These are often premonitory 
of organic disease of the brain. 

Treatment. — There is a tendency to disparage treatment, 
especially as to impressing the system with medicines. Exper- 
ience has proved the great benefit which generally results 
from properly conducted treatment, and that it is often essen" 
tial to the continuance of life. It should be kept in mind that 
there is generally a tendency to recover. 

The objects of treatment are : 1. To cure a patient as soon 
as possible, restoring the functions and organs to their normal 
state, without entailing any structural change. This is called 
" curative treatment" and is a reality. 2. Some cases require 
a sustaining treatment until they run a certain course, without 
expecting to effect an immediate cure; only actively interfering 
when untoward symptoms arise, the object being to prevent death 
and permanent injury. Some kind of fevers furnish exam- 
ples. 3. Unfortunately in some cases death is inevitable ; 
then the aim of treatment is to contribute to the comfort of 
the patient in every way possible, and to prolong life. 4. Symp . 



8YMPT0MAT0LGY, OR SEMEIOLOGY. 29 

toms are frequently present which it is the chief object to re- 
lieve, or remove. This may be paliative, or occasionally cura- 
tive, as the removal of ascites and other forms of dropsy may 
give a long period of immunity from affliction, although the 
organic lesion which leads to dropsy may remain. A symptom 
should not be suppressed, at the risk of the disease, as a cough 
is often a necessity for expectoration ; it must not be stopped . 

5. Preventive treatment includes : to obviate the tendency to 
disease ; the prevention or the extension of disease ; the warding 
off of habitual attacks, as epilepsy, asthma, acute dyspepsia, etc.? 
the avoidance of complications; the rooting out of various con- 
stitutional disorders ; and of contagious diseases from commun- 
ities, etc. 

6. Instances often occur when the chief treatment consists 
in warning the patient to carefully avoid doing things that may 
result in bodily harm, as in certain cases of cardiac disease ; those 
subject to gout, rheumatism, predisposed to phthisis, etc. To pre" 
vent maladies is a higher function than dispensing drugs. 

Indications. — In treating an individual case a definite object 
should be deduced from the symptoms present. The indications 
may be derived from : 1. The seat, nature and stage of the 
disease. 2. The causes of it. 3. The condition of the patient 
as to age, constitution, etc., as well as surrounding circumstances. 
4. The symptoms present, which may either point to measures 
to be used, or contra-indicate a particular treatment which should 
be otherwise pursued. 2. The condition of the principal bodily 
organs, as the heart, lungs, kidneys, etc. It should be the rule 
to ascertain their condition. This often controls the indications. 

Treatment consists of three kinds, therapeutic, diatetic and 
hygeinic, each requires careful observance. Therapeutic treatment 
means the use of medicines. Their proper employment will do 
much good, and they are often indispensable. When special 
remedies which have a curative action upon certain diseases 
are unknown, then we have to use them in various combinations, 
according to certain principles, thereby obtaining great benefit- 

Dietetic Tkeatment. — This is indespenable. The body must 
be sustained by nourishment. It can not be on medicines, cer- 
tainly. Often a patient needs only proper advice as to diet- 



30 SYMPTOMATOLOGY, OR SEMEIOLOGY. 

Directions must include the nature of the food ; the quantity, at 
what intervals, etc. Personal examination of the food of a 
patient is often important, and special directions may be needed 
as to how to prepare it, as beef tea, etc. Alcoholic stimulants re- 
quire great care in their administration. 

Hygeinic Treatment. — This includes attention as to place of 
residence, its hygeinic conditions, ventillation, etc., habits of life, 
exercise, clothing, change of air and climate, etc. In treating 
acute cases, especially all forms of fevers, it is imperative on 
the physician to personally inspect the sick-room, regulate the 
ventillation, its cleansing, the condition of the bed, the removal 
of excessive curtains, or carpets, and everything, even of minor 
importance. A competent and faithful nurse, who understands, 
or can be readily instructed in correct hygeine, is vastly import- 
ant in every grave case. Ordinarily a nurse should merit and 
receive credit for a cure, second only, to the attending physician* 
Every available attention should be given to the comfort and 
well-being of a patient. 

Topics. — External applications are available and very useful 
in treatment. These will be fully described in treating individ- 
ual diseases. 

Common sense is an essential factor in managing cases of dis- 
ease. Difficulties, ever varying, often formidable and perplexing, 
require the exercise of much thought, patience and sound discre- 
tion. Every case should be studied upon its own merits ; deduce 
the rational indications and fulfill them. It is better to pursue 
a well known and often proved course of treatment, than to hazard 
experiments with new, and, to us, untested remedies, however re- 
commended. Medicines impress the system, either favorably or 
otherwise. It is not enough to follow authorities. The practi- 
tioner who assumes the responsibility to treat disease, must be 
authority to himself. New remedies (to us,) should be first 
tested upon our own persons, as a rule. 



RULES FOR THE PRACTITIONER. 81 



MULES FOR TEE PRACTITIONER. 

Physicians will find the following, or similar simple rules, very 
useful in the daily routine of professional duties : 

1. The object of treatment is to restore health as speedily, 
pleasantly and safely as possible. TV hen the spontaneous efforts 
at cure are progressing favorably toward recovery, it is unwise 
to interfere with drugs. 

2. When a remedy is indicated, and a choice is possible, 
select the one which is most agreeable in its action, and without 
injurious results upon the body. 

3. Prescribe medicines in the forms which are most accepta- 
•ble. Conceal, if possible, offensive odors and tastes, especially 

with " sensitive patients " and children. 

4. When there is an idiosyncracy as to any special medicine? 
or form of it; or as regards any particular diet, avoid prescribing 
them. Extreme susceptibility to the influence of certain drugs, 
odors, tastes, and food, sometimes exist, and it is unwise and un- 
safe to combat known peculiarities. 

5. The condition of the patient when the medicine will act 
must be regarded, as a sudorific, when the patient must be exposed 
to the open air, would prove worse than useless. 

6. Incompatible medicines in a prescription, or in two which 
alternate each other, must be carefully avoided, unless intended to 
form a new compound. When alkalies are indicated and used 
lemon or other acid drinks are obviously improper. And vice versa. 

7. Incurable diseases require alleviation. Giving no undue en- 
couragement, it is a humane duty to render waning life as com- 
fortable as possible, and extend it to the utmost limit. 

8. Do not prescribe or allow the use of quack medicines, or 



32 RULES EOR THE PRACTITIONER. 

Secret remedies, and none whose composition is not understood. 

9. Good advice must be given from time to time, and pains 
taken to impress the patient and attendants with the importance 
of thoroughly carrying out the directions. Superstitions and pre- 
judices must be kindly met and overcome without giving offense- 
Hope and confidence are indispensable factors, in chronic cases, at 
least. The patient who has faith in the doctor will recover much 
sooner ceteris 'paribus than one who is shy or incredulous. 

10. Prescribing medicines without the proper diet or manage 
ment, is only half doing duty. Directions must be given in plain 
detail — as to proper places for the bed, ventillation, amount of 
light, position in the bed, degree of quiet, exclusion of callers, 
cleanliness of the patient, and the nature, quantity and interims of 
food. No cooking in the sick-room. In protracted cases, one bed 
for the day and another for the night is desirable. The spread of 
infectious disorders must be timely and carefully prevented 
Soiled clothing, dirty water, etc., must be removed, A bed-pan 
containing a disinfectant, ought to be used to receive the evacua. 
tions, and promptly carried out. 

11. Formula should not be prescribed with servile exactness. 
All medicines of any power have to be adapted to the condition of 
each case. "A bundle of ready-made receipts, in the hands of the 
routine practitioner, is but a well-equipped quiver on the back of 
an unskilful archer.*' 

12. All cures are not our cures. The medicines given may not 
have been taken, or may not have been absorbed, or its properties 
may have been destroyed by adulteration, or it may have worked 
injury, even — a recovery in spite of the disease, medicine and the 
physician. 

13. " The poor you have always with you," is a humane appeal 
which cannot fail of the proper and ready response by a profession 
which fully appreciates the sufferings and necessities, often aggra- 
vated, prolonged and more fatal among the poorer classes of our 
common humanity. 



ItYPER^MfA, OR CONGESTION. 83 



SECTION II. 

It is now proper to consider certain morbid conditions which 
are included in "general pathology," and acquire a comprehensive 
knowledge before considering them in connection with special 
diseases. 

CHAPTER I. 



Hyperemia, or Congestion. 

These signify excess of blood in a part. The cause, and the 
vessels in which accumulation chiefly occurs, give character to 
the hyperemia, as active or arterial ; mechanical, or venous ; passive, 
or capillary. 

I. Active, or Arterial. — " Determination of blood." The 
arteries are mainly aifected, an increased afflux of blood passing 
through them ; usually too much blood also passes out through the 
veins; the circulation is accelerated, the arteries are dilated, 
either because the pressure becomes extraordinary, or they can 
not resist it. 

Symptoms and Effects.- -More or less bright redness, with 
turgescence and increased temperature, are the objective signs of 
"active congestion." Visible pulsation and increased or altered 
secretion may be apparent. The vessels may become ultimately 
distended to a degree to exude serum, or even to rupture and 
cause hemorrhage. Heat, fullness, and throbbing are the subjec- 
tive symptoms ; or the functions of a part or organ may be mater. . 
iaily affected, as observed in the lungs or nerve centers, producing 
severe symptoms. If this congestion continues a long period, it 
may terminate in hypertrophy, or induration ; the arteries becom- 
ing permanently thickened and dilated. 

Causes. — 1. Paralysis of the muscular coat of the arteries, 
yielding to the normal pressure of the blood. This paralysis may 
be due to direct injury to the spinal cord, or to the sympathetic 

5* 



34 HYPEREMIA, OR CONGESTION. 

trunk, as the pressure upon the sympathetic trunk by an aneurism 
in the neck, congestion results ; by reflex irritation through the 
sensatory nerves, as congestion from a sinapism ; heat or cold, or 
due to excessive use or increased activity, as in the eye or mam- 
mary gland, or accruing from severe neuralgia. Many internal 
congestions are probably due to this cause Causes acting through 
the brain are apparent, as emotional blushing and the effect of 
certain poisons. 

2. The rapid withdrawal from arteries of external support, cause 
their dilation and congestion : the result of applying a cupping-glass 
to the skin, thus removing the common pressure of the atmosphere. 

3. The pressure on internal vessels may be increased by the 
augmented force of the heart, or because some vessels being oblit- 
erated, and others compelled to do increased work, unduly distend- 
ing them ; as, when a main artery is tied, the " collateral circula- 
tion " is rapidly increased ; or, when otherwise suddenly blocked. 
Internal congestions are often due to this cause, following exposure 
to cold, due to constriction of the skin, thus driving the blood 
inwardly. 

II. Mechanical, or Venous. --No excess of blood enters a 
part in this form of congestion. It consists in obstruction to its 
passage, hence the veins and capillaries are languid in action, 
become overfilled with dark blood. This is an important form of 
congestion, often calling for the special attention of the practitioner. 

Symptoms and Effects. — If superficial, the objective signs are : 
Redness of a dull, dusky, purplish, or livid hue ; distension and 
often knotted condition of the capillaries and veins ; increase of 
bulk, and frequent lowering of temperature. At length serum 
exudes containing some solid constituents of the blood, causing 
" dropsy, 1 ' and greater enlargement, with softness, pitting on pres- 
sure. Sometimes there is a fibrinous exudation, giving a brawny 
and firm feel, as after obstructions in the veins of the leg in 
phlegmasia dolens. In congestion of the kidneys albumen may be 
found in the urine. Congestion of mucuous surfaces leads to 
watery flux. 

In more intense congestion the coloring matter of the blood 
exudes, or the red corpuscles migrate through the walls of the 
vessels into contiguous tissues ; or finally the vessels may rupture 
and hemorrhage result, as in varicose veins; as the bJeeding in 



HYPEE^EMIA, OR CONGESTION. 35 

the stomach, or intestines, which results from obstruction of the 
portal vein. If the vessels are weakened the same may occur in 
the structure of organs, as well as on free surfaces. 

When the congestion is excessive, rapidly produced or long 
continued, nutrition ceases and ulceration or gangrene may result. 
A u thrombus " occasionally forms in a congested vein, as in the 
portal vein in cirrhosis of the liver. Mech anical congestion of the 
organs or tissues will lead to permanent thickening or enlargement, 
forming a fibroid material, causing stiffness, induration and loss of 
contractility. The subjective symptoms vary with the parts con- 
gested. Usually there is sense of weight, or dull, heavy uneasiness. 
The functions of the' affected parts are more or less impaired. The 
external parts often feel numb and cold when the seat of venous 
congestion. 

Causes. — 1. A mechanical interference with the venous circula- 
tion through parts is the usual cause. If seated in the heart, it 
affects the entire systemic, or pulmonary circulation, or both, due 
to the precise locality of the obstruction. Only some special 
veins, or system of veins, may be affected, such as the portal, or 
those of a limb, it being a local impediment. The obstruction may 
be within the vessels, as a thrombus; external pressure ; or con- 
striction, as from a ligature, cirrhosis of the liver, etc. 

2. Dependent parts are quite liable to congestion from the 
force of gravitation, especially if the tissues are relaxed and yield- 
ing, or the " vis atergo'' is deficient; as in the congestion of the 
veins ot the legs, after long standing, and in hemorrhoids, resulting 
from sedentary habits. 3. Deficient vis a tergo frequently occasions 
this form of hyperemia, or predisposes to the action of other 
agencies in its development. The heart, or arteries, may be 
weakened in their action, contractility and elasticity due to degen- 
eration, impairing the forces of circulation, and devoid of force to 
drive the blood through the veins, as is quite common in very 
old age. 

III. Passive or Capillary. — There is a distinction between 
mechanical and passive congestion, though many authors associate 
them. The circulation is very languid through the capillaries, due 
to disturbance in the vital and nutrative relation between the 
blood and elementary tissues. The state of the part is similar to 
that existing in mechanical hyperaemia. Atrophy of, and degener- 



36 HYPEREMIA, OR CONGESTION. 

ative changes in, the tissues are likely to result, and there is a 
liability to low, asthenic forms of inflammation, with a chronic 
tendency. 

Causes. — A debilitated condition of the body induces passive 
congestion; due to feeble circulation, deficient nutrition, and an 
atonic state of the tissues. Dependent parts, and those distant from 
the heart, are especially prone to it, as coldness and blueness of 
the extremities, ears, nose, etc. The hypostatic congestions in 
various low fevers and prostrating diseases, are partially of 
this class. 

2. Passive congestion may be due to morbid conditions of the 
blood, as when it is insufficiently areated, and deficiency of fibrin 
also favors its advent. 

3. Anything which locally debilitates or impairs any organ or 
part and the functions of its tissues, render them liable to become 
the seat of passive congestion ; as in paralized limbs, and what 
follows functional activity of an organ exhausting it. It may be 
the result of active congestion or inflammation, due to tne per- 
verted relations between the blood and tissues, as is frequent after 
tonsilitis, etc. 

Post Mortem Appearances. — The essential character of this morbid 
state is redness, varying in tint and form according to the nature of 
the congestion. Bright red denotes active congestion, in the form 
of minute net- work, or it may appear uniform, or in points when 
certain special structures are affected. There may have been 
active congestion in life, yet no postmortem redness apparent, due 
to arterial contraction expelling the blood into the veins ; minute 
extravisations of blood sometimes render red points apparent. 

Yenous congestion is more or less dark red, or it may be bluish, 
or purple ; the veins are visible and distended in net work form. 
The post-mortem gravitation of the blood into the dependent parts 
often gives the appearance of congestion where none had existed. 
Post-mortem staining by the coloring matter of the blood may 
simulate congestion. The results of congestion, as described, may 
be apparent after death ; as dropsy, etc., and where it bad long 
continued, considerable changes in appearance and structure] are 
readily seen. The pigment derived from the coloring matter of 
the blood often gives a gray or dark hue to the parts. 



DROPSY. 37 



CHAPTER II. 



DROPSY. 

Dropsy, formerly correctly called hydropsy, signifying water 
appearance, is often described as a disease, while in reality it is only 
a prominent symptom due to some local or general morbid condition. 
An accumulation of water, or serous liquid in some one or more 
of the natural serous cavities of the body, or in the meshes of the 
areoler tissue, or in both, often appearing independently of in- 
flammation. 

Causes. — 1. Obstruction to the return of venous blood, over- 
distending the veins and their capillaries, due to various different 
conditions. The most common of these are : Valvular or other 
disease of the heart. Ketarded circulation and increased fullness 
of the veins, as in pulmonary emphysema, bronchitis, etc. Struc- 
tural disease of the liver, or impeding the return of blood through 
the portal system of veins. The pressure of tumors, enlarged 
glands, and the gravid uterus, etc., on veins. 

2. It may be caused by kidney disease, due to imperfect elim- 
ination of uiea, and water also accumulates in the blood. 

3. It may be also due to anaemic or watery blood. 

4. Inflammatory hyperemia leads to it, as is seen in pleuritic 
effusion, strumous hydrocele, etc. 

The various forms of dropsy are : Anasarca ; ascites ; hydrocephalus ; 
hydrothorax ; hydropericardium ; hydrocele, etc. The dropsical 
affections will be separately considered in detail with other indi- 
vidual diseases. 

General Treatment. — The indications are : 1. To remove when 
possible, or when not, to relieve the diseased condition of which 
dropsy is a symptom or expression. 

2. To carry off the liquid and restore the normal state. These 
indications point to the use of purgatives, diuretics, emetics, diaph- 
oretics, and topics. To alteratives, tonics, etc., as restoratives. 
When the accumulation of liquid cannot be carried off through the 



38 DROPSY. 

natural channels, which ought to be the first effort, as a rule, then 
resort must be had to tapping ; incisions, or accupuncture and 
issues. 

Purgatives. — Among those which have been found most efficient 
are : Apocynum, Compound powder of jalap and Cream of 
tartar, equal parts. Compound podophyllin pills. Elaterium. 
Black hellabore. Turpentine emulsion. Khubarb. Colocynth, 
etc., termed hydragogue cathartics. 

Diuretics. — Digitalis. Dwarf Elder. Infusion of Buchu and 
Uva ursa. Copaiba, or its resin. Nitrate of potam. Spirits of 
nitrous ether. Acetate of potash. Compound spirits of horse- 
radish. Oil or spirits of juniper. Benzoate of amonia and digit- 
alis. Liquor potassae. Fomentations over the loins Cupping 
the loins. Dry cupping over the kidneys, etc. 

Emetics. — Ipecacuanha. Mustard. Compound emetic powder, 
or acid emetic tincture, etc. 

Alteratives. — Iodide of potassium. Alterative syrup. Syrup of 
corydallis eompositus. Chlorate of potash. Colchicum. Arsenite 
of potassa, etc. 

Tonics. — Citrate of iron and amonia. Tartarated iron. Pyro- 
phosphate of iron. Nitro-hydrochloric acid. Citrate of iron and 
quinine. Hydrastus canedensis, and other vegetable tonics. Cod- 
liver oil. Tincture of perchloride of iron, etc. 

Topics. — Fomentations. Hot-water baths. Hot-vapor baths. 
Hand baths Frictions, and sometimes unguents, etc. 

Treatment must be directed to build up the general system ; 
especially to improve the state of the blood. The digestive and 
nutrative functions claim the first attention. G-ood, nourishing and 
digestable diet is indispensable, and that which is apetizing In 
short, everything must be done to improve the blood and the gen- 
eral system. Cleanliness of dropsical parts is necessary, and to 
avoid pressure upon them. 



HEMORRHAGE. 39 



CHAPTER III. 



HEMORRHAGE. 



Hemorrhage signifies the escape of blood from the natural chan- 
nels or vessels of circulation. The heart may rupture, or the blood 
may escape from either the arteries, veins, or capillaries. Capil- 
lary hemorrhage is most frequent in medical practice. As a rule 
the vessels are ruptured, but the bleeding may occur without 
actual rupture. Often no lesion can be detected by the most care- 
ful scrutiny, and it is known that both the red and white cor- 
puscles can escape through the coats of the blood vessels. 

The blood may be poured out on a free surface, as that of the 
skin, or on a muco us or serous membrane, or into the interstices of 
tissues, into the substance of organs, or into morbid growths. 

Varieties. — 1. Traumatic — When a vessel has been directly 
divided; and spontaneous, when the bleeding is due to some consti- 
tutional condition. 

2. Symptomatic, when clearly the result of disease, as in tubercle, 
cancer, etc., and idiopathic, or essential, when no such cause exists. 

3. Active hemorrhage is that resulting from active congestion, 
or active inflammation, and it is termed passive when debility of 
the system and poverty of the blood exist. 

Hemorrhages occurring at intervals are called constitutional, and 
seem to promote the general health, as bleeding from piles in 
plethoric people. 

Vicarious hemorrhage is supplemental to some other, as a woman 
having periodical bleeding from the nose in place of the usual cata- 
menial flow. 

Critical hemorrhage is one occurring during the progress of dis- 
ease, producing a marked injurious effect. 

The foregoing classification is of no great practical importance. 

The seat of hemorrhage generally varies with the age of the 
patient. Bleeding from the nose is more frequent in youth ; from 
the lungs, bronchi, stomach, urinary passages, and uterus in 



40 HEMOREHAG& 

adults ; and from the cerebral vessels, and rectum late in life. 

Special terms are used to indicate the source from which the 
blood escapes, as epistaxis, bleeding from the nose ; haemoptysis, from 
the air-passages or lungs ; hcematemesis, from the stomach ; malaena, 
from the bowels ; hcematuria, from the urinary organs ; and Menor- 
rhagia, from the female genital organs. 

The pathological conditions to which these hemorrhages are due 
will be explained more fully hereafter, in connection with individ- 
ual maladies. 

Prognosis. — This will depend upon : 1. The quantity of blood 
lost. 2. The seat of the hemorrhage. 3. The condition of 
the patient, and the immediate obvious effects of the bleeding. 
4. ^Whether it is possible to stop the hemorrhage, or whether it 
is likely to recur. 

General Treatment. — 1. Perfect quiet, in a cool apartment. Sim- 
ple unstimulating food and drink. Position, such as to prevent 
afflux of blood to bleeding organs. Turpertine stupes. Ligatures. 

2. Remedies. — These vary in different cases, with the various 
causes to which they are due. The available general means are : 
Cold applications, as ice and cold water. G-alic acid. Tannin. 
Mineral acids. Amonio sulphate of iron. Tincture of perchloride 
of iron. Creosote. Ipecacuanha. Oil of turpentine, titrate of 
silver. Alum, salt, kino. Matico. Ehatany. Ergot of rye 
Opium. Digitalis. Aperients. Transfussion, etc 

Hemorrhagic Diathesis. — r Ihis is usually congenital or may be 
due to insufficient nourishment ; or sometimes caused by a diseased 
spleen. In this there is absence of coagulable constituent of 
the blood. 

Symptoms. — Echymosis. Dropsy. Painful swelling around joints. 
Bleeding from umbilicus after birth ; from the nose or gums in 
youth ;from the urinary passages and rectum in age. Fatal loss of 
blood after leech-bites ; extraction of teeth, rupture of hymen, etc. 

Treatment— Avoid surgical operations. Caution after accidents 
Nourishing food, etc. Eemedies are those indicated in passive 
hemorrhages. 



INFLAMMATION. 41 






CHAPTER IV 



INFLAMMA TION. 

This is a morbid action of vast importance. Inflammatory affec- 
tions are so common and numerous, that the student and practi- 
tioner require a thorough acquaintance with the subject in order 
to become qualified to perform their daily functions with the 
proper skill and success. The medical man is not interested so 
much in the various profound theories upon the pathological 
changes involved, as in a plain statement of all Xh.Q essential points 
pertaining to this subject. There are questions connected with 
inflammation, the full discussion of which does not properly come 
within the province of this work. 

Inflammation. — From inflammo, to burn. Synon. Phlogosis ; 
Phlegmasia; Hyperhcematosis.- -Sometimes a destructive, sometimes 
a formative, process; consisting essentially of local congestion, 
and stagnation ( stasis ) of the blood, with exudation of liquor 
sanguinis, emigration of white corpuscles, and proliferation of 
these and cell elements of the affected part. 

I. Changes Observed by the Microscope in Inflamed Tissues. 
These may be studied by irritating the transparent vascular 
tissues of animals, and watching the effects. The web of a frog's 
foot, its tongue or mensentery, and the wing of a bat, are most 
commonly used for this purpose, and the following phenomena 
are apparent: 

Changes in the Blood-vessels and Circulation. 

1. The Blood-vessels become Altered. — In almost all cases there is 

an immediate dilatation of the small arteries with elongation and 

tortuosity, which increases ten or twelve hours, and then remains 

stationary. A primary contraction rarely occurs, of short duration. 

7* 



42 INFLAMMATION. 

After a time the veins enlarge, their shape becomes changed into 
little bulgings and contractions, giving rise to a variocose or 
aneurismal appearance. Structural changes in the capillary walls 
occur in the course of time, becoming the seat of fat-granules, 
especially around the nuclei, and they send out processes by bud- 
ding, which finally unite together. 

2. The Circulation is Disturbed. — First an increased rapidity in 
the flow of blood! except when contraction occurs. This is soon 
followed by a rather sudden change to the normal rate of move- 
ment, then becomes slower, which begins in the veins. A to-and- 
fro oscillation is then often seen, and finally complete stasis, or 
stagnation occurs, the vessels appear crowded with red corpuscles. 
Neighboring vessels often present all these various conditions as 
to movements, and around the center of stasis, the vessels are 
usually overloaded, the circulation slow ; while beyond this still, 
the flow is increased in activity. 

3. Important Phenomena Occur in the Blood Corpuscles. — The white 
corpuscles accumulate in the vessels, especially in the veins adhering 
to their walls, forming a continuous motionless layer, the current 
continuing until stasis occurs. After a time the corpuscles pene- 
trate the walls of the capillaries, and may be seen in various stages 
of their transit, forming button-shaped elevations, then hemispher- 
ical prominences, then pear-shaped bodies, and finally separating 
altogether. This process is due to the power which these corpus- 
cles possess of spontaneous movement, of altering in shape, and of 
digesting the protoplasm of the vascular walls, by virtue of their 
amaboid nature, so that no actual opening is left, showing where 
they have escaped. The name of " leucocytes " is now given to 
these escaped white corpuscles. After they leave the vessels they 
send out processes, assuming peculiar shapes, and ' ; migrate " far 
and wide into the adjacent tissues; at the same time, often under- 
going a process of division, and becoming increased in number. 

The red corpuscles show the same tendency to aggregation and 
stasis, and they may so adhere that their outlines are quite ob- 
scured. They often also " migrate " through the walls of the 
vessels, but not nearly to the same extent as the white blood-cells. 
Dr. Lionel Beale states that, in an inflammation, little particles of 
bioplasm, or germinal matter, of the blood, pass through small rents 



INFLAMMATION. 43 

or fissures in the capillary walls, and afterwards grow and multiply 
by division. Some of these are detached from white corpuscles. 
He assumes that most of the particles seen outside of the vessels 
originate in this way, not from the direct transit of white corpuscles. 

4. An Exudation of Liquid More or Less Approaching to "Liquor 
Sanguinis'' Generally Occurs, Not Invariably. — There is [always a 
tendency to the escape of fluid from the vessels of inflamed tissues, 
which, though usually called " liquor sanguinis," is rarely iden- 
tical with it in composition. It may be mere serum, but as a rule it 
contains fibrin albumen, also a considerable proportion of phos- 
phates, chlorides, and carbonates. Its nature and quantity will 
vary according to the seat and intensity of the inflammation. 

In parts which have no vessels, the alterations which have been 
described can be seen in contiguous tissues, from which the nutri- 
ment for the non-vascular structures is derived. 

Changes in the Affected Tissue. 

The nutrative processes are rapidly disturbed when inflamma- 
tion sets in, and in some structures this is the only perceptible 
deviation from health, there being no appreciable amount of exuda- 
tion. Such inflammations are termed u parenchymatous,'' and are 
noticed in cartilages, and certain organs, such as the kidneys. 
The first tendency is to the active formation of cells, or cell-prolifer- 
ation, or germination, which is due to the increase in size of those 
already existing, and of their nuclei, and the division of the latter 
along with the protoplasm of the cell contents, so as to form new 
cells (endogenous) formation. They also undergo many changes 
in form, and exhibit amgeboid movements. This cell-proliferation 
is in proportion to the intensity of the inflammation, but greatly 
varies in the different tissues. 

In epithelial structures it is very rapid ; less so in connective 
tissue, cartilage, bone, and the cells of organs, and does not occur 
at all in the higher tissues, such as nerve. These new cells are 
prone to decay, especially when they are quickly formed, and the 
inflammation has been very active; yet they may develop into a 
permanent tissue, which tends to be of a lower organization than 
the original one. When intercellular substance exists, it often 
softens and breaks down, and the entire structure may be com- 
pletely destroyed at last, the histological elements be involved in 



44 INFLAMMATION. 

the degeneration. Dr. Beale describes the " bioplasm" of inflamed 
tissues, as increasing greatly in amount. 

II. Nature and Origin of Inflammation, with the Explan- 
ation of the Phenomena Observed. 

The present views of the phenomena of inflammation are that 
they are due to disturbance in the mutual vital relations of tissues, 
blood-vessels and blood. This pathological process, affecting the 
nutrative conditions, results from some injury to, or irritation of, a 
tissue, direct or indirect. An impression is thus produced on the 
centripetal or sensory nerves, which is communicated to the 
vaso-motor centre, there reflected to the centrifrugal or vaso-motor 
nerves, and conveyed by them to the vessels, which consequently 
dilate, because of a paralyssis of the muscular coat. The primary 
acceleration of the flow of blood may be due to dilatation, the 
subsequent phenomena are the result of some alteration in the 
vital properties of the living tissues, including the coats of the 
vessels and the adjacent structural elements. The former are so 
deranged as to lead to stasis, and to allow of the free passage of 
liquid and leucocytes, having lost their resisting power. The cell- 
proliferation, and increase of bioplasm are due to the direct influence 
of the abundant supply and frequent change of the nutrative fluid, 
the "liquor sanguinis," in stimulating growth and development. 

The primary irritation may immediately set up this overgrowth, 
or it may be originated through the nerves directly, and may itself 
tend to promote a free escape of fluid from the vessels, because it 
causes a greater demand for nutriment It is the opinion of able 
pathologists, that the whole process of inflammation is due to a 
direct change in the vessels or blood, set up by the molecular 
tissues of the part affected, and that it is not produced through the 
medium of the nerves. 

III. Eesults and Products. 
1. Resolution. — The changes already described having occurred, 
to a greater or less extent, what is termed resolution may occur, 
which means a subsidence of the vascular disturbances, and the 
absorption of any exudation, leaving the tissue normal. Any 
leucocytes which are present either undergo fatty degeneration 
before absorption, or re-enter the blood-vessels or lymphatics. 



INFLAMMATION. 45 

Resolution may take place very rapidly, and it is then named deli- 
tescence ; or metastasis may occur, — the disappearance of inflammation 
from the part, with its simultaneous development in another. 

2. Exudation and Effusion. — There is an escape of fluid from the 
vessels in inflammation, varying much in quantity and composition. 
These effusions include serwn, fibrinous exudation or lymph, blood, 
and mucin. 

Serum. — This effusion is seen in connection with serous mem- 
branes, or in the sub-mucous tissue in certain parts. It is not 
uniform in its composition and characters, but contains a variable 
amount of albumen, and generally fibrin also, with considerable 
phosphates and chlorides. It may continue for a long time unal- 
tered, or is absorbed, if the inflammation subsides or may become 
changed into pus. 

Fibrinous Exudation, Lymph, Coagulable Lymph, Inflammatory Exu- 
dation. — In some forms of inflammation an exudation escapes from 
the vessels which is coagulable, containing much fibrin, the above 
names are applied to it. There is really no line of distinction between 
this exudation and the serous effusion resulting from inflammation. 
It has a number of leucocytes in it, as well as cells, resulting from 
proliferation, and Dr. Beale describes it as containing more or less 
of the particles of " bioplasm." Often organization tends to occur 
in it, but others think that only the cells and bioplasm become 
developed, the lymph nourishing these ; while some are of the 
opinion that the fibrin coagulates and fibrilates, and itself contrib- 
utes to the formation of new tissues. 

There are two kinds of lymph — the plastic, or fibrinous, which 
contains abundant fibrin-forming ingredients, tends to coagulate 
and develop tissues; and the aplastic corpuscular, or croupous, in 
which there are a large number of cells, with slight tendency to 
organization, but rather a proneness to degeneration and to the 
formation of pus or other low products. The condition of the 
patient, the seat and intensity of the inflammation, and other 
causes, influence the nature of the exudation materially. 

After the subsidence of the inflammation, the cells which are 
derived from leucocytes, or from proliferation in the affected tissue, 
as also the masses of germinal matter, may become developed and 
organized. Some form of connective or fibrous tissue is generally 



46 INFLAMMATION. 

produced, but bone, elastic tissue, epithelium, or fat, may be ulti- 
mately formed. Certain of the higher tissues are never developed 
under these conditions. The organization into new tissue is well 
seen in the changes which occur in the granulation-tissue by which 
wounds cicatrize, and in the adhesions and thickenings formed in 
connection with inflamed serous membranes Very serious conse- 
quences often attend these changes, structures become thickened, 
hardened, contracted, or bound together, and transparent tissues 
rendered opaque. 

A process of degeneration sets in after organization, as wasting 
or withering, the substance becomes dry, yellow, horny, and stiff, 
by a fatty or liquafactive change, which leads to its absorption, or 
by the formation of black pigment. Changes similar may occur in 
the products of corpuscular lymph. 

In a majority of tissues the cells which undergo development are 
at first derived from leucocytes, afterwards others are formed by 
cell-proliferation. 

Blood is sometimes present in inflammatory exudations. It is 
partly the result of migration of the red corpuscles, but may be due 
to the actual rupture of vessels, especially recently formed ones. 

Mucin — In some inflammations of mucous membranes this 
substance is found, and it gives a tenacious, stringy character to 
the fluid discharged from the surface. 

3. Suppuration, or Formation of Pus. — The tendency to this 
process varies according to the tissue affected, and the constitu- 
tional condition, and it generally is more liable to occur if the 
inflammation is very severe and concentrated. Pus may form on 
a free surface, and be discharged, and often mixed more or less 
with other material; it may accumulate in cavities, such as those 
lined with serous membranes ; or it may involve the substance of 
organs and tissues, in the form of a circumscribed abscess, or as a 
diffuse purulent infiltration. 

Physical Character of Pus. — Thick, viscid, pale yellow liquid, 
odorless, alkaline in reaction, with a specific gravity of about 1030. 
It consists of a fluid, " liquor puris," in which float pus-corpuscles, 
and other microscopic particles. Liquor puris is an albuminous 
fluid, but also contains salts, pyin, chondrin, and fat. The cor- 
puscles closely resemble pale blood-corpuscles in size and appear- 



INFLAMMATION. 47 

ance, being more or less round, or sometimes irregular, granular, 
and having one or more nuclei, which are made more apparent by 
acetic acid, and often break up when acted upon by this re-agent. 
They have the power of spontaneous movement and migration, and 
they can alter in form, and increase in number, by fusion. 

Dr Beale describes pus-corpuscles in the living state, as masses 
of bioplasm, without cell wall, which assume a variety of forms, 
but never spherical, send out protrusions in every direction, these 
becoming detached and forming new corpuscles, and which are 
capable of spontaneous movement. When dead, they assume the 
spherical form, their movements cease, a kind of cell wall forms, 
they become more granular, and bacteria are developed in them. 
In this condition they are usually seen under the microscope. 

It is now generally considered that the most of these cells, 
especially in the earlier stages of inflammation, are merely white 
blood-corpuscles which have migrated, — leucocytes. Beale be- 
lieves they are derived from the particles of bioplasm which escape. 
Afterwards others are formed by proliferation of the other cells 
and germinal matter of the tissue affected, and they increase in 
number by cleaverage and endogenous formation. These " leuco- 
cytes " possess the power of destroying the tissues with which they 
come in contact, and it is partly in this manner that an abscess 
makes its way to, and opens on the surface. 

Various Kinds of Pus. — " Healthy or laudable, ' " ichorous or 
watery," " serous," " sanious,'' etc. For further knowledge of 
these, the reader is referred to surgical works, to which it properly 
belongs. Pus may decompose and form noxious gases, and it 
sometimes undergoes physical and vital changes, if not discharged, 
its fluid portion being absorbed, its cells becoming withered, and 
undergoing fatty degeneration, so that it is converted into a cheesy 
mass, containing fat-granules, shriveled cells, and neuclei. 
| 4. Softening of tissue is not an uncommon result of inflammation, 
and it may proceed to such a degree as to cause the complete 
breaking up of the affected structures. This is illustrated by the 
softening resulting from inflammation of the brain. 

5. Induration is another consequence of inflammation, especially 
when chronic, or due to the substitution of an imperfect fibrous 
tissue for the normal structure. 



48 INFLAMMATION. 

6. Interstitial absorption is sometimes observed, as in the case of 
osseous inflammation. 

7. Ulceration. — An ulcer is the result of the destruction of the 
tissues on the surface by inflammation. If this is quite superficial 
only the epithelium being removed, it is called excoriation, or 
" abrasion." Ulcers frequently come under the notice of the 
physician in connection with mucous surfaces, and they present 
many differences in form, size, and appearance. A discharge of 
pus usually occurs from the surface after the inflammation process 
subsides. An ulcer tends to cicatrize, by the development of 
granulation-tissue into fibrous tissue, which afterwards is prone to 
contract, leading to serious results. Ultimately the original struct- 
ures may be developed anew, but a 1 ong time passes before this is 
attained, and some tissues are never reproduced. 

8. Gangrene, or Mortification.— Rapid death of the involved parts 
may result from very severe inflammation, under certain conditions^ 
and a slough forms, becomes isolated from the living textures, and 
undergoes a process of separation, leaving an ulcerated surface. 
This is the result of direct injury to the vitality of the structure," 
of the stagnation of blood, and of the injurious effects produced by 
the exudations. Almost any tissue may mortify from this cause, 
but it is specially common in the subcutaneous areolar tissue, and 
in the mucous membrane of the alimentary canal. Gangrene is 
rarely seen in organs. The gangrene is of the " moist" kind, and 
therefore the slough is prone to decomposition. Different tissues 
are liable to different kinds of inflammation as to products and 
terminations. This is readily seen by the results of inflammation 
affecting serous and mucous membranes respectively. 

Serous inflammation is at first marked with redness, loss of polish, 
opacity and thickening of the membrane. Then a fibrinous 
exudation is deposited on the surface, varying in amount, charac- 
ter, and arrangement, which contains abundant cells, chiefly 
leucocytes, but partly derived from cell-proliferation in connection 
with the epithelium-particles. Simultaneously an affusion of fluid 
occurs, into the serous cavity, turbid, and containing coagula, and 
abundant cells, similar to those in fibrinous layer. The furthef 
tendency is to the absorption of this fluid and forming of thicken- 
ings, adhesions, or agglutinations in connection with the serous 



INFLAMMATION. 49 

membrane. Pathologists now incline to the opinion that the 
fibrinous layer is not organized but undergoes fatty degeneration, 
becomes absorbed, and that the adhesions are produced by the 
development of minute vascular papilla?, or granulations, which 
form on the surface of the membrane under the epithelium. If 
the inflammation is intense, or long continued, the fluid may 
become purulent, and this is apt to occur in certain constitutional 
conditions. r £he general tendency of serous inflammation is to 
produce material capable of organization. 

Mucous membranes are subject to three varieties of inflammation : 
Catarrhal; croupous; membranous, plastic or fibrous; and diph- 
theritic. 

Catarrhal. — This is the common form. It begins with conges- 
tion and swelling of the membrane, at first abnormally dry. 
Soon there is an increased secretion of viscid mucous, containing 
abundant cells, derived from the proliferation of the epithelium 
and from leucocytes, and if inflammation continues, the discharge 
assumes a purulent appearance, due to the large number of cells 
mixed with it, many of the precise character of pus-cells. The 
follicles and glands enlarge and fill with cells. Sometimes the 
sub-mucous tissue becomes infiltrated, and if loose, considerable 
serum may collect in it. Abrasion or ulcers are frequently pro- 
duced If infiltrations become chronic, considerable changes in 
the structure of the glands and membrane. 

Croupous. — This differs from catarrhal in that a layer of "false 
membane " is deposited on the surface, varying in consistence 
and thickness. This consists of coagulated fibrin, either amor- 
phous or fibrillated, including epithelium and pus-cells. It has 
recently been described as being constituted of altered epithelium- 
cells without any fibrin. It is, however, distinctly fibrilated in 
some cases, but evinces no tendency to organize. 

Dipatheritic. — This is characterized by a fibrous exudation not 
only upon, but into and beneath the mucous membrane, which is 
destroyed and converted into a slough, and an ulcerated surface is 
left. The difference between inflammations of mucous and serous 
membranes is thus made apparent. 

In that of mucous membranes the products have no tendency 
to organize, owing to the abundance of cellular elements being 



50 INFLAMMATION. 

discharged with the secretion, while those of serous membranes 
are retained for organization. 

IV. Symptoms and Signs. 

1. Local; Objective. — In visible parts, it generally presents 
three well-recognized objective signs of change : Redness, swell- 
ing and heat. Redness varies in degree and hue, generally tending 
to be bright. Toward the centre of inflammation this is more 
marked, gradually fading, until lost at the circumference, disap- 
pearing more or less on pressure. This is due chiefly to overload- 
ing of the vessels and blood stasis, but partly the result of 
migration of red corpuscles, or rupture of vessels, and extravasa- 
tion. Non-vascular tissue cannot have redness, but the neighbor- 
ing structures which nourish it exhibit the redness. Owing to 
the contraction of arteries, redness may disappear after death. 

Swelling. — This varies greatly, accompanied by hard or soft 
feeling, due to the increased amount of blood in a part, and the 
various exudations and effusions poured out, also the proliferation 
of tissue, these explain the enlargement wnich is often troublesome. 

Increased local heat is frequently quite apparent to the touch, 
or at times it can only be detected by the thermometer. This is 
mostly due to the great activity of nutrative and chemical changes 
in the part, but to some extent to the increased flow of blood 
through it. Dr. Beale attributes the increased heat to the rapid 
growth of bioplasm. 

The same objective changes obtain in internal inflammation, but 
cannot be observed in life ; careful physical examination, hereafter 
to be explained, will often enable us to determine the physical 
condition as to the presence of exudations and effusions internally. 

Subjective, — Pain is commonly present in inflammation, though 
it may be absent, and it varies in intensity and kind, in different 
tissues. Tenderness is usually present and may exist alone. 
Functions of structure and organs are always disturbed, and often 
those of adjacent parts are implicated. Secretions are always 
changed in quantity and cornpositon. 

General or Constitutional. — Acute fever, usually of the inflam- 
matory type, at first, varying much in degree, due to the tissues 
affected. It is " symptomatic " or '•sympathetic/' When sup- 
puration begins, a shivering usually occurs, and the fever is ap 



INFLAMMATION. 51 

to become hectic. If gangrene supervenes, typhoid fever is present. 
The state of the blood is hyperinotic, having an excess of fibrin, 
coagulating firmly, often presenting the " buffy '' coat Water is 
excessive, but salt and albumen are deficient. The red corpuscles 
run together, and form " rouleaux, " under the microscope. The 
fever is due either to paralysis of the vaso-motor nerves, or the 
whole blood is raised in temperature by the local production 
of heat. 

Y. Causes. 

Predisposing causes not only influence the occurrence, but also 
the part inflammation affects, and the variety it assumes. 

1. The general condition of the system and the blood power- 
fully predispose to inflammation Weakness, impoverished blood, 
due to deficient food, disease, vicious habits, bad hygiene, etc. 
The reverse condition : plethoric, over feeding, stimulating, lux- 
urious life, render persons exceeding prone to attacks. 

Poison in the blood is the most important general condition, 
often of special kind, and affects particular tissues, as eruptive 
fevers, syphilis, diabetis, gout, rheumatism, etc. Old people and 
children are most liable, but not of all structures. Persons of 
sanguine temperament are most liable to inflammation. 

2. Local. — Mechanical or passive congestion, defective nutrition 
of a part, vessels in a state of degeneration, as in old age, etc. 

Exciting causes are mechanical injury or irritation from without 
or within, as wounds, bruises, worms, tumors, extravasated blood, 
retained excretives, concretions, deposits, etc. 

3. Chemical Irritants. — Great heat or cold. A specific inflam- 
mation from croton oil, tartar emetic, a blister, etc. Contact of 
air to irritated or ulcerated surfaces, or pus, or gangrenous fluids, 
come under this head. 

4. Introduction of specific poisons induces inflammation, small- 
pox, vaccination/glanders, syphilis, gonorrhse, etc. 

5. The cause may exist in the blood itself, by the introduction 
from without of a chemical or organic poison, as arsenic, canthari- 
des, etc , or a contagious poison, and produce special results. One 
inflames the stomach and the other the kidneys, while various 
acute fevers show special inflammatory eruptions, and peculiar 
disorders of organs and structures. Irritants may be generated 
within the body, as in gout, rheumatism, or in successive destruc- 



52 INFLAMMATION. 

tion of tissues, the materials thus formed act as exciting and pre- 
disposing causes of inflammation, which are called secondary. 

6. Cold and wet, acting on the skin, while the body is per- 
spiring, produce a "chill," which is followed by internal congestion 
and inflammation. The small cutaneous vessels contract and drive 
the blood inwardly, and also interfere with cutaneous excretion, 
causing noxious accumulations in the blood. These are termed 
idiopathic or primary inflammations. 

VI. Varieties. 
It is acute or chronic according to intensity and rate of progress. 
Sthemic or asthenic according to symptoms present. Plastic, ad- 
hesive, suppurative, or gangrenous according to the products and 
terminations of inflammation. Circumscribed or diffuse. Healthy, or 
phlegmonous, or unhealthy. Non-specific, or specific, the latter includ- 
ing syphilitic, gouty, strumous, tubercular and other specific forms 
of inflammation. 

Symptoms of Inflammation. — For clearness these may be 
aggregated and summed up : Pain. Swelling. Heat. Eedness. 
Blood, when tested, is buffed and cupped. Diminution of red 
corpuscles, and increase of fibrin : Perhaps an increase of color- 
less corpuscles, and increase of the blood. Symptomatic fever. 
Depression. Eigors. Frequency of the pulse. Headache. Thirst. 
Loss of appetite. Furred tongue. Diminution of chlorides in the 
urine. Increased excretion of urea. Sweating. Hectic fever. 
Excessive wasting. Prostration. 

Varieties and Results. — Adhesions. Suppurations. Ulcerations. 
Hemorrhage. Sloughing. Gangrene. 

VII. Treatment. 

Only a general treatment is proper here, and it is very difficult 
to give even an outline of it, because inflammation varies so much j 
under different circumstances and conditions. In giving individ- 
ual inflammatory diseases the proper treatment will be carefully 
set forth in detail. For the present, only the main details wiU 
be given. 

1. If conditions exist likely to give rise to inflammation, take 
measures to prevent it. After an injury the part should be kept at 
rest, and appropriate means applied. The condition of the blood 



INFLAMMATION. 53 

which tends to secondary inflammation should be corrected If 
paralysis of a nerve exists all sources of irritation must be avoided. 

2. Subdue the inflammation as soon as possible, and thus 
prevent unfavorable results. If any exudations and effusions have 
been poured out, limit them, or procure absorption, or remove 
them in some other way as soon as possible, and restore to the 
normal state. Guard against suppuration, ulceration and gangrene, 
and treat them promptly when they occur. Treat the general 
condition — fever, constitutional disorder, etc. Attend to local 
symptoms and the special character of the inflammation. 

Remove the cause if possible ; enjoin perfect rest. Position must 
be such as to prevent accumulation of blood. Antiphogistic 
remedial measures must be employed to lessen vascular action, 
both in the quantity of blood present and its rate of movement 
Modern practice has substituted for venesection, aconite, veratrum, 
digitalis, etc., as sedatives in inflammation. 

An important class of remedies in some cases, if prudently 
employed, are those which increase the various excretions, and 
thus relieve the blood-vessels, as purgatives, diuretics and diaphor- 
etics. It is very important to restore and keep the secretions, the 
bowels open and the liver in proper action. Purgatives, to a due 
extent, are important in inflammation of the liver. 

Local Measures. — Applications of cold in the form of evaporating 
lotions ; cold water, cold irrigations, ice, etc. Only in the early 
stage these remedies are mostly useful, and when the inflammation 
is superficial, or near the surface. 

Seat and moisture, in the form of hot water dressings ; poultices 
and hot fomentations act very beneficially in many cases. In 
other instances sinipisms and even blisters may be required. All 
these determine the blood to the surface, a necessity in all forms 
of internal inflammation. Yarious forms of counter-irritation are 
recommended, as painting with a solution of iodine, irritating 
liniments, unguents, etc., as also various baths, which often prove 
efficient means in getting rid of various effusions. 

Operations for the removal of the products of inflammation may 
be required when they cannot be otherwise disposed of. Certain 
acts may be requisite in other cases to promote the discharge of 
certain products, as coughing in bronchitis, etc. 



54 DEGENERATION. 

The various forms of fever present must be treated by the prin- 
ciples laid down on each subject respectively. 

If any specific inflammation exists, particular constitutional reme- 
dies are indicated, as alkalies in rheumatism, colchicum in gout; 
tincture of iron in erysipelas, chlorate of potash in inflammation 
of the mouth and throat, etc. 

Diet is very important, and must vary according to circum- 
stances. In depression, it may be sustaining, and stimulation may 
be also required. In suppuration and gangrene, tonics are neces- 
sary, as mineral acids, steel, cod-liver oil, cream, etc. The hygienic 
conditions must receive careful attention. 

Pain is a prominent local symptom, which requires careful at- 
tention. Opium has been much employed in various forms to allay 
irritability ; to quiet the peristalic action of muscular tissues ; to 
induce sleep, and to directly influence the inflammatory process. . 
It is proper here to warn practitioners against its use when the 
respiratory organs, the kidneys, or the brain and the spinal 
cord are involved. Hydrate of chloral and other sedatives are often 
better and more appropriate to secure rest and relieve pain. 



CHAPTER V. 



DE GENERA TIONS. 



Degeneration implies the conversion of one tissue into another, 
less organized, and which is incapable to suitably perform the 
necessary functions. It is a retrograde metamorphosis. This is 
due either to a change of albuminoid compounds, or to molecular 
absorption of the structural elements, and their replacement by 
others, lower in the scale. This term is also applied to certain 
morbid processes when new material is deposited among the normal 
elements of a tissue ; it being derived from the blood, may not be 
absorbed, or entirely replace them. Metamorphosis is the term 



DEGENERATION. 56 

applied to the former, and infiltration to the latter of these"two 
kinds of degeneration. 

1. These pathological changes interfere with the functions of 
organs or tissues. 2. They produce conditions which predispose 
to the occurrence of dangerous lesions. A fatty heart is liable to 
rupture, and a fatty or calcified condition of the :E blood-vessels very 
often result in their laceration, and extravasation of blood, as well as 
aneurism. Hence this subject assumes great practical importance. 

I. Fatty Degeneration. 

This comprises fatty metamorphosis and infiltration, each requir- 
ing distinct consideration. 

1. Fatty Metamorphosis. — The direct conversion of albuminoid 
constituents of tissues into fat is common to decay in old age, and 
is fraught with serious results. It may occur with the cells or 
fibres. The fat usually deposits in a granular form, but finally 
accumulates in masses or drops of oil. These granules are recog- 
nized by their distinct and dark outline, their solubility in ether, 
and their refractive power upon light. 

Muscular Tissue. — The voluntary or other muscles may become 
the seat of fatty change. The whole muscles may be converted 
into fat, without any alteration in their general size or shape, or in 
the arrangement of their fibres. This most frequently occurs in 
the fibres of the heart. Under the microscope the fibres are seen 
somewhat dim at first in their transverse striae, due to the presence 
of a few minute fat-granules, arranged in longitudinal or trans- 
verse lines, or usually in an irregular form. Ether renders the 
striae apparent. Increase in the size and number of these granules 
obscure them more and more until all trace of muscular fibre 
disappears, leaving nothing seen except fat-molecules and oil-drops 
occupying its course. When the sheath surrounding the fibre 
(sarcolemma) exists, it may finally rupture, and the fat be scat- 
tered. The conversion of muscle into adipocere after death, is a 
fatty degeneration. 

Blood-vessels — As age advances, the arteries are quite prone to 
fatty degeneration. This may originate .in the cells of the inner 
coat, or in the muscular coat, or associated with " atheroma,"' 
which will be described. At length the tissues may be destroyed 
and carried away 3 with the blood, leaving uneven erosions on the 



56 DEGENERATION. 

inner surface of the vessels. The capillaries are also apt to under- 
go a fatty change. The nerve tissues, fibres and cells are liable to 
fatty degeneration, become the seat of molecular fat and ultimately 
break up. The varieties of softening of the brain and spinal cord, 
exhibit striking specimens of fatty degeneration. 

The so-called " compound inflammatory globules," or " exuda- 
tion-corpuscles," as also " pus-corpuscles," are merely due to the 
conversion of the contents of cells, either normal to the part or 
migrated from the blood into fat. Many of these have their origin 
in cellular-tissue corpuscles. Fatty degeneration also occurs in 
the cells of the liver, lymphatic glands, epithelium of the renal- 
tubes, supranal capsules. " Arcus seniles " is due to the same 
process in the conea. In their natuial decay most organs undergo 
this change, which is also manifest in various secretions, as well 
in the production of the corpus leutenum in the ovary ; the degen- 
erative changes in the placenta approaching the full period of 
utero-gestation Various tumors, tubercles, cancer and other 
morbid growths are capable of fatty change. 

Cells enlarge, are more spheroidal and distended when they 
become fatty. The granules first appear distant from the nucleus, 
irregularly scattered; then become larger and more numerous, 
obscure the nucleus, and finally obliterate it. The cell-wall is 
often ruptured or absorbed, followed by accumulation of granular 
fat, which often separates its constituent particles from interme- 
diate liquafaction. 

Caseation, Caseous or Cheesy Degeneration. — Lately these terms 
have become quite prominent to designate the conversion of differ- 
ent structures into a kind of soft, dryish, cheesy-appearing sub- 
stance of yellowish color. This material consists of withered cells, 
fat-granules, partially saponified fat, and chrystals of chloresterin. 
It mostly occurs where there is a large accumulation of cells, 
crowding together, especially where vessels are sparse, and the 
tissues dry. Pulmonary phthisis affords frequent examples of this 
process of partial fatty degeneration, but of necessity associated 
with tubercle. It is often seen in chronic abscess, as scrofulous 
lymphatic glands, diseased bones, cancer, etc. Ultimately a creamy 
or puriform, or a fatty emulsion may be'produced. It may be ex- 
pectorated, or qtherwise discharged, and thus caseous matter may 



DEGENERATION. 57 

escape. It may be incapsulated by some dense tissues, and finally 
calcify. 

Effects. — The immediate effects of fatty degeneration may be 
obvious; in the earlier changes, the microscope alone reveals the 
change. The affected tissues become paler, with a reddish or 
brown tint ; well seen in muscles ; and in the brain. It varies from 
white to red. There is a tendency to opacity. The most marked 
alteration is the tendency to softening of structure until it breaks 
down under pressure, into almost a fluid pulp. Vital properties, 
as elasticity, or contractility, are impaired or lost. In the advanced 
stage the tissues have an oily feel, and ether dissolves out consid- 
erable fat. 

Great importance attaches to the remote consequences. The 
functions of organs are impaired, or lost. Structures are liable to 
yield or rupture, as in the heart or vessels. Arteries thus affected 
are liable to aneurism, etc. 

Causes. — Interference with nutrition. The causes are : 1. Sen- 
ile decay, in which most tissues degenerate. 2. Deficient supply 
of arterial blood to a part from obstruction, external pressure, 
changes in the vessels. 3. Some constitutional disease, lowering 
vitality. 4. Congestion, inflammation, rapid development of tis- 
sue, excessive use of functions, which disturbs vitality. 5. Excess 
of fat in the blood may possibly aid this degeneration. 

2. Fatty Infiltration. — This process is essentially distinct from 
" fatty degeneration." No change in the tissues, but merely ex- 
cess of deposit of fat from the blood within the cells of the affected 
part, infiltrating the structure : a hypertrophy of fat. It occurs, in 
oil-drops, running together, obscuring the contents of the cells 
without destroying them. The best examples of this infiltration 
are seen in the increase of adipose tissue in some persons, subcu- 
taneous and around the internal organs; also in the muscular 
tissue, especially that of the heart ; and in the hepatic cells. In 
the first two the connective tissue cells become filled with fat. 
The degree of change in the heart is from a slight increase, to be- 
come converted into adipose tissue, no trace of muscular fibre, or 
only few scattered ones, the most of them having undergone real 
fatty degeneration from pressure, and then removed. This process 
may also occur in paralyzed voluntary muscles, and those rendered 
otherwise inactive. The cells of the liver become pitted with oil- 



58 DEGENERATION. 

drops, enlarge, become more spherical, and hide their contents. 

Effects. — Fatty infiltration enlarges organs, alter them in form, 
tending to roundness in margin and outline. The color becomes 
paler, and may be even to that of adipose tissue. Softening, with 
a doughy feel, like ordinary fat, much oil present as seen on the 
knife, the fingers, blotting-paper, or by ether, are the chief changes 
observed. This process interferes with the functions of tissue, but 
not to the extent as in fatty degeneration unless they have suffered 
from pressure. 

Causes. — 1. Excess of fat in the blood is a common cause of this 
morbid change, and is attended with obesity. This is due to ali- 
ments which contribute to its formation, and want of proper exer- 
cise, and general luxurious habits combined. There is also less 
than the common waste of fat under such conditions. 

2. It is a singular fact that in some diseases, attended with great 
emaciation, some organs are prone to fatty infiltration, especially 
the liver. This is manifest in phthisis, due to the general absorp- 
tion of fat, its consequent accumulation in the blood from which it 
is deposited in the liver. 

3. Interference with respiration may lead to fatty infiltration, be- 
cause the fat is not properly consumed, hence, the occurrence of 
such heart and lung degenerations are explained in part, at least. 

4. Local inactivity may induce fatty infiltration, as has already 
been explained, for want of muscular inactivity, etc. 

II. Mineral or Calcareous Degeneration. — Calcification. — 
Petrification. 
This degeneration must be distinguished from ossification, there 
being no conversion into bone, but merely an infiltration of the 
tissue with particles of calcareous matter. These are in the form 
of minute molecules, irregularly deposited between the histological 
elements. Microscopically they appear like dark, opaque, irregu- 
lar particles by transmitted light, and have a glittering look in 
mass- They resemble fat, but are soluble in dilute mineral acid, 
attended with effervescence, giving off bubbles of gas, due to the 
decomposition of carbonates. This deposit occurs around small 
vessels first, then may extend and form irregular concretions of 
various sizes. This chiefly consists of calcic and magnesic phos- 



DEGENERATION. 59 

phates and carbonates, other salts being present, the chemical 
composition differs in the different structures. 

Calcification occurs in parts which have lost their vitality by 
undergoing other changes of degeneration, especially fatty. It is 
in fact the last degeneration possible. The auricles, valves, and 
orifices of the heart are most commonly affected by it, and where 
the worst effects are produced It may occur in fibrous, or fibro- 
serous membranes as the dura-mater, the pericardium, tumica 
albuginea, etc., also in the walls of hollow organs, as the stomach, 
gall-bladder ; the pia-mater and choroid plexuses of the brain, 
constituting ( " brain-sand " ; in muscle, cartilage, nerve tissues ; 
in various glands and organs, as kidneys, lungs, absorbent glands, 
prostate, thyroid and pineal glands ; in withered tubercle, cancer, 
inflammatory exudations, fibrinous deposits from the blood, tumors 
of all kinds, and chronic abscesses. 

Effects. — Calcareous deposit produces hardness, roughness, stiff- 
ness, rigidity and brittleness. There is a gritty sensation, and in 
membranes they are easily broken. Stoney masses of some size 
are sometimes formed; occasionally a chalky fluid is produced, 
similar to cement. The change in shape and size of structures, the 
roughness, brittleness, interference with movement and functions, 
elasticity and contractility are serious results. It narrows arter- 
ies, renders them rough and rigid and easily ruptured, hence the 
supply of blood is deficient, and consequent atrophy or gangrene 
results ; also the formation of internal clots, or extravasation of 
blood and hemorrhages. It causes serious cardiac obstruction and 
interference with its functions. In some cases calcification is a most 
favorable process, as in phthisical deposits, and in lymphatic 
glands. A cure is sometimes thus effected, and may remain for 
years inert, causing no disturbance. A mass may form in the 
abdomen of the scrofulous, and give little inconvenience, and the 
patient may die of quite a different disease, or some acute one. 

Causes. — 1. Deficient vitality and lowering of nutrative activity 
in general, and advanced age, or local as morbid products, and is 
due to insufficient supply of blood, with tardy circulation. It is 
often the termination of atrophic and degenerative processes. 

2. Due to excessive salts in the blood. This may be due to dis- 
eases of the bones, mollities ossium, necrosis, or extensive caries, 



60 DEGENEKATION. 

in which their salts are actively absorbed, and " metastatic depos- 
its " take place in other tissues, often involving many organs and 
structures. Deranged urinary secretion may lead to this condi- 
tion, the salts being retained, the kidneys are prone to become the 
seat of deposit. 

III. Fibroid Degeneration. 
Structures are sometimes changed into inelastic, tough, imperfect 
fibres, similar to fibrous tissue. A hyperplasia of cellular elements 
occur without much exudation. The part is opaque, whitish, stiff, 
and thickened, occasionally rough and hard. The serous andfibro- 
serous membranes often show this change in thickened patches 
like those seen in the pericardium. The covering of the liver, 
spleen, and sheaths of vessels are frequently affected by it. Also 
the cardiac valves, tendinous cords and muscular tissue, interfering 
with their functions, and may end in calcification. It is due to 
friction, pressure, repeated traction, and sometimes to long- 
continued congestion. To define the line between this process and 
chronic inflammation is often difficult. Some pathologists hold 
that fibroid degeneration is always the result of chronic inflam- 
mation. 

IV. Pigmentary Degeneration. Pigmentation. 

Various causes may change the color of tissues, as in jaundice, 
local staining with bile, the bronzed skin in suprarenal disease, color 
due to gases, or matters set free in mortifying parts, and that in- 
duced by the long use of nitrate of silver. The deposit of actual 
pigment in various tissues ; its origin, nature, and the character 
of the difterent kinds are to be considered here. 

1. It exists in the coloring matter of the blood; it undergoing 
certain changes, either from transudation, migration of red corpus- 
cles, hemorrhage, or of capillary stagnation, it may be present in 
a part. It is at first diffused, staining the tissues, especially the 
cells, leaving the envelope and nucleus unstained. At length it 
shows various tints, as yellow, yellowish-brown, brown, dark 
brown, reddish -brown, gray, or black ; depending upon the duration 
of the existing pigmentation ; separating into molecules or chrys- 
tals, or both, within and outside the cells. The chrystals may 
aggregate in large granules, round or irregular, well-defined, 



DEGENERATION. 61 

opaque, or sometimes glistening. These resist acids, and are inde- 
structible, except by strong alkalies, forming a red solution. It is 
supposed to consist of " hseniatoidin," but when black it is termed 
neianin. These are found in cerebral apoplexy, in pulmonary 
congestions or hemorrhage, extravasated blood in " corpus luteum '' 
in the ovary ; " in rusty expectoration " of pneumonia in its pro- 
gress ; and in certain diseases of the blood itself contains particles 
of black pigment, as in the rare disease named melancemia, in pro- 
tracted ague, seen in enlarged spleen, supposed to be absorbed 
from the blood. This condition also obtains in melanotic tumors, 
and sometimes black pigment fills the portal vessels of the liver. 
It occurs in growths connected with the tissues which normally 
contain much pigment, as the choroid coat of the eye. 

5. Pigmentation in the bronchial glands and lungs is often due 
to the inhalation of certain matters with the air, as particles of 
carbon, owing to imperfect combustion. From this cause the 
lungs become darker as age advances, or owing to certain occupa- 
tions, as colliers, miners, stone-masons, etc. Minute granules of 
carbon, resisting chemical change, after entering the small bron- 
chi and air-cells penetrate the epithelium cells and tissues, 
between the lobules and around the bronchi, lying there free, or 
inclosed in the connective tissue corpuscles. Being taken up by 
the lymphatics and conveyed to the bronchial glands, which be- 
come black. Abundant pigment is seen in the black expectora- 
tions, due to abundant deposit of foreign matter and the irritation 
and inflammatory process, and stagnation of blood thus occasioned. 

V. Mucoid Degeneration. 

Certain tissues occasionally undergo a process of liquefaction, to 
which the term mucoid is applied. They are changed into a homo- 
geneous mucillaginous, colorless mass, which yields mucin. They 
seem to return to a foetal condition. This change may be limited 
to spots, or may become extensive. When the former, they are 
surrounded with normal tissue, and show the appearance of cysts. 
The intercellular tissue is most involved, sometimes the cellular 
elements are drawn into this degeneration. Cartilages, bone, ser- 
ous membranes, and the choroid plexes of the brain become the 
seats of this process. Certain tumors are of a " mucoid ' character 



62 DEGENERATION. 

from their origin, and many others, to a greater or less extent, 
undergo this form of degeneration. 

VI. Colloid Degeneration. 
This substance is of glue-Jike or of a jelly consistency, devoid of 
color, glistening and transparent. Derived from the albuminoid 
tissues, it differs from mucin by including sulphur in its composi- 
tion, and acetic acid will not precipitate it It involves the con- 
tents of cells, not the intercellular structure. Finally it may embrace 
considerable masses, which appear to be in cystic cavities. " Col- 
loid tumors " sometimes start as new growths, and certain other 
tumors are prone to this change. Now " Colloid tumors " are not 
recognized as cancers, as heretofore, and it is at present considered 
that non-malignant tumors may become the seat of this degenera- 
tion. Enlarged lymphatic and thyroid glands contain this material 
occasionally. 

VII. Lardacious Disease. — Albuminoid Infiltrations. — Amy- 
loid Degeneration. — "Waxy Disease. 

A very important morbid condition of organs and tissues have 
recently been described under the above names. Much is yet to 
be ascertained about this morbid process. The present state of 
knowledge in this regard may give a tolerably fair comprehension 
of the subject. 

1. Characters of the Substance and Objective in the Diseased Tissues m 
— Infiltration of an apparently quite structureless and homogen- 
ous, and, at first, nearly transparent material constitutes this dis- 
ease. Said to give certain characteristic chemical reactions. An 
aqueous solution of iodine applied to the affected part sometimes 
produces a deep reddish-brown color, but chiefly useful to indicate 
slight infiltration, especially in microscopic sections. If an organ 
or tissue is much affected it enlarges, sometimes to a great degree, 
without irregularity, surface smooth, margins rounded ; weight is 
proportionately increased, specific gravity is high, and the organ 
feels solid, firm and heavy. It is a combination of toughness, re- 
sistance and elasticity, somewhat resembling wax and lard corn- 
combined ; hence the names "waxy" and " lardaceous." A sec- 
tion shows a glistening, translucent appearance ; dryish, pale, 
compact, quite smooth and uniform. It maybe limited to certain 



DEGENEKATION. 63 

spots or to vessels, and is well seen in sago-spleen, confined to the 
malpighian corpuscles. It generally most affects minute capillar- 
ies and arteries, the infiltration originating in the muscular coat- 
The walls thicken, the channel narrows, and -in section the vessel 
remains open, assuming a compact, shining translucent aspect 
like silvery threads or cords. In due time the material extends to 
the cells, enlarging and making more spherical, displacing the 
normal contents and destroying the nucleus. Then they coalesce 
giving the whole structure a peculiar glistening aspect. 

2. Nature and Origin. — Many attribute to this substance some- 
thing allied to starch and cellulose, hence the term " amyloid " ; 
in others a form of chloresterim. It is now generally conceded to 
be albuminoid, a nitrogeneous compound. Dr. Dickinson holds it 
to be deallcalized fibrin. Most pathologists consider it a direct deposit 
from the blood, due to some alteration in that fluid, occurring 
under certain conditions. Nothing of this albuminoid nature has 
ever been detected in the blood, and most likely it is modified after 
its escape from the vessels. In local lesions this is a general 
disease. 

3. Organs and Tissues Affected. — It may involve any part or struc- 
ture, usually several organs are involved in this morbid process, 
The kidneys, liver, spleen and absorbent glands are most prone to 
it. Other structures, as the stomach, intestines, bones, suprarenal 
capsules, muscles, brain, cord and their membranes, the tonsils, 
serous membranes, the bladder, etc Morbid deposits in connec- 
tion with inflammation, cancer and tubercle, it also affects. It 
originates in the lymphatic glands, when it follows disease of the 
bones, and some, therefore, favor the local origin of this degen- 
eration. 

4. Causes and Diseases with which it is Associated. — Some previous 
disease almost always produces it, in which there has been a chronic 
and excessive suppuration, but not indispensible, as some very grave 
cases of the kind have occurred without previous suppuration. 
Separate conditions under which it may occur are caries, necrosis, 
and rickets ; after syphilis, especially if attended with suppuration 
and affection of bones ; or if much mercury had been employed. 
Albuminoid disease affects children who are congenitally syphilitic. 
Also chronic pulmonary phthisis, and other lung maladies, attend- 



64 DEGENERATION. 

ed with large purulent expectoration. In chronic empyaemia ; ex- 
tensive intestinal ulcerations ; after long malarial influence or 
ague ; in kidney disease and pyelitis. 

5. Clinical History and Symptoms. — Only a general history is 
necessary here, as the symptoms will be given in connection with 
this disease in individual organs. In albuminoid disease we have 
impaired nutrition ; emaciation, pale and anaemic, with transpar- 
ency of tissues, and a waxy appearance. Often great debility, and 
proDeness to syncope. The legs are oedematous, due to weakness 
and an aemia. Various organs are enlarged, and their functions 
greatly impaired. 

6. Treatment. — The general indications are to counteract the 
cause and suppress the suppuration, etc. The general health must 
be improved by proper nourishment, hygienic measures, tonics, iron, 
and other remedies, as indicated in different cases. Syrup of iodide 
of iron, when persevered with often gives good results. 



CHAPTER VI. 



FEVER, OR PYREXIA. 

A correct knowledge of "fever" as a general condition is es- 
sential to proper appreciation of it as symptomatic, or resulting from 
special disease. The symptoms indicating " pyrexia " are so com- 
mon that it is very important to acquire clear views of the nature 
and effects of fever on the general system. Fever may naturally be 
divided into two distinct classes : 

1. When the symptoms of fever constitute the primary devia- 
tion from health, not due to any local cause, it is termed idiopathic, 
primary, essential or specific, or it is simply called a fever. Some 
morbid poison in the blood, introduced from the outside, or pro- 
duced within the body, is the cause. Rheumatic fever affords a 
specimen of this class. 



FEVER, OR PYREXIA. 65 

For convenience the general characters of fever will be first con- 
sidered, and then pointed out individual forms which occur. 

2. It may be due to some local lesion or disease in some organ 
or tissue,as an inflammation. This is called the " pyrexial state," 
or secondary, symptomatic, or merely pyrexial fever. The fever attend- 
ing pneumonia illustrates this class. 

Essential Phenomena and Symptoms. — 1. Elevation in temperature is 
considered the only essential sign of fever. If excessive heat 
obtains, a febrile condition exists. The patient feels a sense of 
abnormal heat, or the skin feels hot to the touch. 

These methods of knowledge are unreliable; the thermometer 
is the only positive test, if fever is thought to exist. The tempera- 
ture may be only slightly above normal and does not usually exceed 
105° or 106°, but may rise to 108°, 110°, or even 112° Fahr. In 
certain cases it may continue to rise a considerable time after 
death, as in puerperal peritonitis. 

2. Alterations in the Secretions. — They are diminished in quantity as 
a rule, due to deficient elimination of water, it being retained in 
the body. Hence some prominent symptoms result ; as dryness 
and roughness* of the skin ; although occasionally there are cases 
of profuse perspiration. Derangement of the alimentary canal. The 
salivary, gastric, and enteric secretions are deficient; hence a 
furred tongue ; a clammy mouth ; thirst, but no appetite ; the bow- 
els are usually constipated; nausea and vomiting often occur. 

Urine is scanty and high-colored, very acid, with a high specific 
gravity and a strong odor. It is altered, containing an excess of 
its organized nitrogenized elements, such as uric acid and urea. 
There is also an increase of hippuric acid, sulphates, phosphates, 
and often, not always, coloring matter. The alkaline chlorides 
may be absent, and always deficient. 

3. Changes in the Circulation and Respiration. — The pulse usually 
bears almost an exact proportion. to the temperature, as a rule. It 
is increased in frequency, and may increase from normal to 120, 
140, or even 160, beyond which it cannot be accurately counted. 
In other respects it greatly varies in different cases. It may be- 
come very weak in long-continued or severe cases, irregular or 
intermittent, due to feeble action of the heart. The use of the 
sphygmograph indicates the state of the circulation in lever cases. 



66 FEVER, 

Alterations in the Blood. — The alkalies are diminished, and the 
alkalinety of the serum ; in a brief period the red corpuscles and 
albumen diminish, while the white corpuscles increase. The fibrin is 
much above the normal quantity in some forms of fever, in others 
it is much reduced. 

Change in Respirations. — These are usually quickened in propor- 
tion to the pulse ; its ratio is always disturbed, mostly in excess. 
The elimination of carbonic acid increased on the whole, due to 
increased frequency of respiration. 

4. Disturbance of the Nervous System — In the early stage, rigors 
or chills ; general soreness or pains ; a general feeling of languor, 
exhaustion, and disinclination to effort. Special local pains and 
headache are frequent in some fevers. Restlessness, insomnia, and 
nocturnal delirium are quite common. In certain cases great 
nervous derangement, indicated by great prostration ; delirium, 
either muttering or violent; stupor or somnolence, tending to 
coma ; muscular disturbance, as tremors, subsultus teudinum ; 
picking at the bedding, or at imaginary objects, convulsions, show 
the great disturbance in the nervous system, incident to fever. 

5. Modes of Termination. — These symptoms, which are varied 
greatly in different conditions of fever, lead to an inquiry as to 
how it may be terminated, or how defervescence may be attained. 

1. By Crisis. — This is indicated by a fall in temperature of the 
body, becoming normal in a few hours ; an increase in the various 
excretions, indicated by copious perspiration, a free flow of urine 
containing much solid constituents, or watery dia.rrhoea. A hem- 
orrhage sometimes occurs, as epistaxis, etc. 

2. Lysis. — This term signifies a gradual defervescence, the 
temperature subsiding regularly and slowly, several days, to the 
normal standard, without critical discharges. 

3. By a Combination of Crisis and Lysis. — In such a case there 
is a rapid fall to a certain point, then a gradual lowering of the 
temperature, or there may be, ( for days, a regular alteration of 

high and low, until the fever subsides. 

4. Defervescence is occasionally very irregular in its course and 
progress, and during convalescence the temperature and the 
amount of excretion are often lower than normal. 



FEVEE, OR PYEEXIA. 67 

III. Type of Fever. — The symptoms of fever, as described, 
are very variously associated with it, and present a large range in 
their severity and course, which gives recognition of certain types. 

Types Depending Upon the Course and Mode of Progress of the 
Symptoms. 

1. Continued. — This includes all fevers without any marked 
variation in temperature at different periods of the day. Acute 
specific fevers, as small -pox, scarlet fever, etc., and those accom- 
panied with inflammation belong to this type. In these the tem- 
perature rises more or less rapidly, up to a certain degree, remain- 
ing stationary for a time ; finally defervescence occurs in one of 
the modes mentioned. 

2. Remittent. — This has marked remissions in temperature and 
other symptoms, succeeded by exacerbations This variety is 
quite common in a warm climate. " Hectic " fever is also charac- 
teristically remittent. 

3. Intermittent. — In this type, intervals, with stated periods, 
run a regular course, and it has a cessation of all fabrile symp- 
toms, which return at certain regular periods, and run through a 
definite course, the temperature in intermission remaining quite 
normal. Examples are found in the various forms of ague. 

4. Relapsing. — As the name indicates, after the continued type 
of some forms of fever, defervescence and apparent recovery 
occurs, then, after some days, a relapse takes place, which may 
occur more than once. Within a few years past, epidemics of this 
type have occurred. 

Types Depending Upon the Combination and Severity of 
Symptoms. 

1. Simple. — Ordinary " febricula " is a good example of this* 
A simple expression of fever, with all the characteristics, without 
any degree of severity. 

2. Inflammatory. — This type is always associated with local 
acute inflammations, at first, as the name indicates. It does not 
invariably bear a proportion to the intensity and extent of the 
inflammation. The young, and plethoric, and those of a sanguine 
temperament are most subject to it. 



68 FEVER; OR PYERXIA. 

The symptoms are marked, varying in severity and of a sthenic 
character. At first there are distinct rigors or shivering, followed 
by a good deal of reaction ; the temperature is high, the skin is 
dry and hot. There is headache, and pains in the limbs. The 
frequent, strong and full pulse shows that the vascular excitement 
is high. The blood contains an excess of fibrin. The tongue is 
thick-furred, but moist, and the breath is offensive ; great thirst, 
with total loss of appetite, and constipation. The urine is scanty 
and very febrile. The patient is restless and sleepless, with noc- 
turnal delirium ; occasionally great nervousness exists at first, 
especially in children, such as delirium and convulsions. 

3. Hyperpyrexia!. — In this the temperature rises very high, 
varying from 107° to 112°, or above ; ascending rapidly, and 
attended with serious symptoms, which are referable to the nerv- 
ous system and organs of respiration, and tending to an early and 
fatal termination. Sunstroke, acute rheumatism, and pneumonia 
are the most frequent examples of this type of fever. 

Low Types of Fever. 

Asthenic, Adynamic — The temperature only slightly above 
normal ; patient very weak ; pulse is feeble and small, though 
frequent, and there is prominent febrile reaction. There is little 
thirst, and the tongue continues moist. There is usually nocturnal 
delirium, without much other brain symptoms. 

Typhoid, or Ataxic. — " The typhoid state " presents some im- 
portant distinctions from the Asthenic. The tongue is dry, and 
covered with a brown crust ; " sordes " covers the gums and teeth ; 
the heart's action is impaired ; the pulse is weak and compressible 
and often intermittent ; there is a tendency to capillary conges- 
tion in depending parts ; the brain symptoms are marked, such as 
low, muttering delirium, muscular tremblings, stupor, closing 
in coma. 

Malignant. — This is of low type, and prone to hemorrhages and 
petechse, hence it is malignant. The terms " septic "' or " putrid '' 
are applied to this type of fever. There is another malignant form 
in which some poison seems to act so violently as to knock down the 
subject of it without local lesion or reaction. 

Hectic. — This attends great drains from the system, as in phthisis, 



FEVEK, OK PYKEXIA. 69 

and is distinctly an intermittent or remittent type, the exacerba- 
tions usually occur once, occasionally twice, in twenty-four hours. 
At first there is only a slight eveDing rise in temperature, and 
quickening of the pulse ; at length it increases, beginning with 
chilliness or rigors, succeeded with much heat toward evening,, 
increasing to or beyond midnight, and is followed with a profuse 
sweat, until the clothes are saturated. The heat is great, with 
burning in the palms of the hands and soles of the feet. There 
is a circumscribed, bright red spot on the cheek, a hectic flush. 
The pulse is easily excited, usually above 100 per minute and may 
rise during the paroxysm to 120 or 130. It is generally jerky, 
soft and compressible. The respirations are short and hurried. 
Eapid emaciation attends this fever and the patient finally is ex- 
ceedingly exhausted. The mind is unaffected until late in the 
case, it is often lively and brilliant. 

Pathology. — This includes the cause, nature, and events in the 
course of fever. Some local irritation, or poison in the blood, may 
originate it, by acting on the nervous system, producing meta- 
morphosis of the bodily structures, and rapid wasting of fat and 
nitrogenized tissues, hence the muscles waste ; also there is atro- 
phy of the nerve centres, ganglia and nerves ; the bones become 
lighter, and the red blood-globules are diminished in number. 
The glandular organs are often enlarged and congested, especially 
in healthy and young subjects. The cells of the spleen, liver, and 
lymphatic glands enlarge and become granular. 

There is an excess of substances produced, which the normal 
processes form, such as carbonic acid, urea, uric acid, etc. Inter- 
mediate products of decomposition are prone to form. There is no 
certainty as to the place where the change occurs. The results of 
this destruction are very important, and are next considered. 

1- Increase of Temperature. — This is caused by the chemical 
and vital changes in the blood and tissues, while the various sub- 
jects undergo oxidation, or combustion, to an abnormal degree . 
The febrile temperature is in proportion to these destructive pro- 
cesses, as evinced by the quantity of material eliminated in the 
various excretions, and otherwise. The amount of perspiration, 
which is usually suppressed in fever, adds to the increase of tem- 
perature, Dr. Beale holds that there is great increase in the bio- 



70 FEVER, OR PYREXIA. 

plasm of the blood, vessels, and tissues : and that insufficient oxida- 
tion loads the blood with noxious materials, which the excretory 
organs are unable to remove. This condition of the blood favors 
the growth of bioplasm. He thus accounts for the increase of 
temperature. 

Excessive Excretory Elimination. — There is, as a rule, a propor- 
tion between temperature and the amount of excretion. To this 
there are exceptions. The usual metamorphosis of tissues forms 
an abnormal quantity of the solid constituents of the urine dis- 
charged, especially urea and uric acid, and an increase in the 
quantity of carbonic acid exhaled. In the progress of some fevers 
there is little or no elimination, and the products of metamorphosis 
are retained in the blood in great excess. Substances are pro- 
duced which the kidneys cannot remove, hence critical discharges 
are more common at the termination of fever, or this favorable 
event may be due to these discharges. 

3. Results of Deficient Elimination. — Typhoid fever results 
from the poison of retained products of metamorphosis. The cir- 
culation of these through the nerve-centres and tissues produce the 
low symptoms, The nervous symptoms have been referred to 
excessive temperature ; or to the plugging of minute vessels of the 
gray matter with white corpuscles. 

Secondary Inflammations. — These are caused by the irritative 
action of the products of destruction of tissue circulating through 
the various organs and tissues. 

Emaciation, Debility and Prostration. — These conditions natur- 
ally result from waste of tissues, and are in proportion to the 
activity of their destruction. Very little food is taken or assim- 
ilated to supply this vast waste. 

Effects on the Circulatory System. — The heart is early excited, 
and finally becomes greatly disturbed and impaired, for obvious 
reasons : Degeneration of the muscular fibres and their impair- 
ment ; it is supplied with impure blood and imperfect nerve stim- 
ulants. Changes in the pulse ; tendency to hypostatic congestions 
and abnormal state of the blood-vessls and tissues , the excessive 
growth of bioplasm, and blocking up of the capillaries are the 
resulting events. These are the main or general points in the 
pathology of fever, to which may be added : The retention of water 



FEVER, OR PYREXIA. 71 

in the body, G-elatin, which has affinity for water, has been said 
to form in the blood. There is no proof of this theory. 

Prognosis. — There are certain conditions which always enhance 
the prognosis of fever ; 

1. Its Intensity. — Danger is in proportion to its intensity. Ke- 
coveries are very rare after the temperature has risen above 107°. 
Eecent cases treated upon a new and vigorous plan go to show 
recoveries after that temperature has been exceeded. 

2. Its Type. — Most forms of fever are grave maladies, and any 
tendency to seriously affect the nervous system, as typhoid or ady- 
namic symptoms, excite anxiety. 

3. Defective Elimination places, a patient in great peril, especi- 
ally if associated with very high temperature. 

5. The Previous State of Health of the Patient. — Kobust, 
plethoric young persons are generally more serously affected than 
those of opposite condition. Some diseases increase in danger, 
such as gout ; the presence of diseased organs, especially the heart 
and kidneys, complicate cases very much. 

General Treatment. — This will depend upon the cause and 
nature of the fever, and whether it is primary or secondary, Every 
case must be treated on its own merits. 

1. Diminish the Temperature, if Excessive. — One of the most 
efficient means for this purpose is the external application of cold. 
This acts by increasing elimination by the skin, and moderating 
the destruction of tissues. Dr. Beale thinks it is by diminishing the 
growth of bioplasm. There are various other modes of applica- 
tion, such as sponging the surface, of the body with water, either 
tepid or cold, as best adapted to the case; by cold affusion or 
douching, which may be done while the patient is in a warm bath ; 
by a wet-packing in a sheet ; by placing the patient in a warm or 
tepid bath, then gradually reducing the temperature, by gradually 
removing the warm and adding of cold water ; by the proper use 
of cold baths; by injecting tepid or iced water into the rectum ;. 
by pulverized ice in bags, which are sometimes applied to the 
head, spine, chest and abdomen, separately, or at the same time. 
After being kept in the bath for a variably time, according to 
necessity, the patient should be wiped dry, followed with brisk 



72 FEVER, OR PYREXIA. 

frictions, and removed to bed, and hot applications to the feet. 
Eepeat the bath several times, if necessary, and apply ice at 
intervals. 

Ordinary cases require only frequent sponging of the surface, 
which is often decidedly beneficial, giving great relief. Cold is 
extremely valuable in cases of high temperature, or shows a ten- 
dency to high elevation. This is sometimes indispensible to 
recovery. 

The more appropriate medicinal agents to lower the temperature 
are* aconite, veratrum virida," and digitalis. These reduce the 
pulse, and thus the temperature, and act, more or less, upon the 
organs of secretion. 

Quinine is used to check the ascent, and lower the temperature, 
and is useful when properly employed. Dilute sulphurious acid 
has been much extolled for this purpose. 

2. Watch the Excretions and observe whether there is the 
proper elimination. Heroic eliminatory treatment^in fever is not 
judicious. The use of aperients, or mild purgatives,, diuretics and 
diaphoretics, are the better means to employ. 

Examine the excretions daily, especially the~ urine. If symp- 
toms indicate the accumulation of urea in the blood, appropriate 
energetic eliminatory measures are required, suclr as free action of 
the bowels and kidneys. 

Diaphoretics and diuretics, such as saline mixtures containing 
citrate of potash or amonia, or liquor amonia] acetatis, with the 
free use of diluent drinks. The use of baths to increase the action 
of the skin ; hot poultices or fomentations over the loins; simpisms 
or dry cupping may be required in grave cases of poisoning by 
urea in the blood, due to want of renal excretion. Great caution is 
requisite not to weaken the patient. Employ supporting measures. 
Saline aperients are better than purgatives. Diarrhoea may be the 
" natural mode of eliminating a poison," but if excessive, it must be 
diminished (not suddenly checked) by appropriate remedies. 

3. Proper Food and Stimulants — This is one of the most 
difficult and essential parts of the treatment of fever. The food 
must be nutritrious and capable of assimilation. Good milk, cream, 
beef tea, eggs, etc..|are valuable articles of diet. The food should 
be given frequently and at regular intervals; in definite and moder- 



FEVER, OR PYREXIA. 73 

ate quantities ; the patient must not sleep too long, without nutri- 
tion. Definite rules are impracticable, as every case must be 
treated as circumstances require. Large quantities of nutriment 
are indispensible in treating low forms of fever. 

Alcoholic stimulants are not always required. Their indiscrim- 
inate use does great harm. In a large number of cases and in 
certain conditions these are indispensible. It requires great 
caution and much experience to suitably administer alcoholic 
stimulants ; the proper amount, etc. Great caution is necessary 
to obtain pure spirits. Wine, brandy, or whisky generally 
answers best. These should be given either diluted, or in the 
form of milk-punch, egg-nogg, etc.; in definite doses and at proper 
intervals. The conditions when its use is indicated may be under- 
stood by the nature of its action. 

1. Its direct action on the nerves of the stomach. It immediately 
stimulates the heart's action, and thus promotes the capillary 
circulation. 

2. After absorption in the blood, it alters the constituents and 
chemical properties of the fluids and solids, and cuts short the life 
of rapidly growing bioplasm, or causes it to live more slowly. 

3. It reduces the permeating influence of the blood serum ; 
renders the walls of the vessels less permeable to fluids ; checks 
the disintegration of blood corpuscles, and has a direct action upon 
the particles of naked and living bioplasm. These are the good 
results of alcohol in cases of fever and inflammations, but only 
when indicated and wisely employed. 

4. Hygienic Conditions. — Attention to these is of vast import- 
ance in connection with fever. Free ventilation is essential, to 
obtain plenty of pure, fresh air, and to drive out that which has 
become vitiated. Cleanliness must be carefully observed. Rest 
and quiet of mind and body must be required. 

5. Special symptoms appear in the course of fever, demanding 
special treatment. Those indicating adynamia, or typhus, invite 
free stimulation ; ammonia, ether, camphor, quinine, nux vomica, 
hydrastin, belladona, mineral acids, etc. Stimulants and tonics, 
prudently given, and the application of sinipisms over the heart. 
Compounds of phosphorous and strong coffee are recommended as 
restoratives. 



74 FEVEE ; OH PYEEXIA. 

Symptoms of exalted nervous excitement are often very trouble- 
some. Hypnotics, to procure quiet and sleep, may become. neces- 
sary, and may be usefully combined with stimulants. If delirium 
or tendency to coma be present, free douching of the head with 
cold or tepid water may be beneficial. Ice-bags may be required ; 
often the application of sinipisms, or a blister to the nape of the 
neck, or sinipisms to the legs and feet are indicated, and often re- 
sult beneficially. 

If nervous symptoms are connected with the retention of excre- 
tions, efficient means must be employed to alleviate them. Symp- 
toms referable to the digestive organs also often call for special 
attention- Nausea and urgent thirst are best relieved by the fre- 
quent taking of small pieces of ice in the mouth, and they are 
precious to suffering fever patients. Vomiting and diarrhsea often 
occur, and must be controlled by remedies to be mentioned when 
considering those symptoms. 

6. Local complications such as hypostatic congestion, and in- 
flammation of the lungs, must be carefully watched for and guard- 
ed against. Position of the patient will have influence against 
these, as elevating the head and chest, and by frequent change of 
posture. Cough and expectoration must be promoted so as to dis- 
charge the bronchial mucous accumulations. Bed sores are liable 
to form, and great care is required to prevent such an additional 
iction. 



7. Convalescence requires watchful care. The practitioner's 
duty is not completed when a severe fever has run its course and 
subsided. Special directions as to diet, hygiene, habits and rest or a ■ 
tives are necessary. ISTormal appetite, digestion and assimilation 
may be secured, by tonics, etc. Excessive muscular exertions and 
fatigue must be avoided until the return of normal strength will 
fully warrant such a venture. A relapse from any cause is a great 
misfortune. 



CLASSIFICATION OF DISEASES. 75 



SECTION III. 

It is now in order to consider individual diseases, and their 
clinical character. Every abnormal condition of the body, or 
any part of it, either in function or structure, are included in the 
term disease. 

The Nomenclature and Classification of diseases have been sub- 
jects of much controversy. They are variously arranged by differ- 
ent able authors and by distinguished bodies of medical instructors. 
As a source of information it is proper here to record some of the 
principal ones. 

CLASSIFICATION OF DISEASES. 

The following classification by Dr. Farre has received quite exten- 
sive approbation : 

CLASS I. 

Zymotic Diseases. — Zymotici. Diseases that are epidemic, endemic 
or contagious ; induced by some specific matter, or the want 
of food, or by its quality. In this class are four orders. 
Order 1. — Miasmotici. Examples: Small-pox, Hospital 
Gangrene, 

2. Enthetici (implanted diseases). Ex.: Syphilis, Hydro- 
phobia. 

3. Dietici. Ex. : Scurvy, Alcoholismus. 

4. Parasitici. Ex : Scabies, Tapeworm. 

CLASS II. 

Constitutional Diseases. — Cachectici ; sporadic diseases, affect- 
ing several of the organs of the body. 
Order 1. Diathetici. Ex.: Ansemia, Cancer. 
2. Phthisici. Ex.: Scrofula, Phthisis. 



76 CLASSIFICATION OF DISEASE. 

CLASS III. 

Local Diseases. — Monorganici (affections of one organ). 
Order 1. Brain Diseases. Cephalici. 

2. Heart Diseases. Cardiaci. 

3. Lung Diseases. Pneumonici. 

4. Bowel Diseases. Enterici. 

5. Kidney Diseases. Nephritici. 

6. Genetic Diseases. Genetici (or organs of repro- 
duction). 

7. Bone and Muscle Diseases. Myostici. 

8. Skin Diseases. Chrotici. 

CLASS IV. 

Developmental Diseases: — Metamorphici. 
Order 1. Of Children. Paidici. 

2. Of "Women. Gyniaci. 

3. Of the Aged. Geratici. 

4. Of Nutrition. Atrophici. 

CLASSIFICATION BY THE COLLEGE OF PHYSICIANS 
AND SURGEONS. 

GEOUP I. 

1. General Diseases. — These affect more or less the entire 
system, and though local morbid conditions are often present, they 
arise secondarily, or as the necessary or accidental consequences 
of the general disorder. Under this class are included : 

(a ) The various idiopathic fevers and certain other affections, 
which are due to the action of a specific poison on the system, 
introduced from without. Ex : Scarlatina, Small pox, Ague, etc. 

(6.) Constitutional Diseases. — These depend upon some unhealthy 
condition of the blood, or cachexia, which is usually revealed by 
local lesions, occurring in several parts of the body at the same 
time, or in succession. Many of them are produced by a morbid 
poison, either entering from without, or more commonly generated 
within the system, or handed down by hereditary transmission. 
In some of these diseases no such poison can be detected. Ex. 
Kheumatism, Scurvy, Cancer, etc. : 



CLASSIFICATION OF DISEASES. 77 

GROUP II. 

II. Local Diseases. — Under this group are described the 
various affections of the different organs and tissues in succession, 
and certain local manifestations of constitutional maladies. 

The foregoing classifications of diseases are among the chief ones 
now followed by authors on the Practice of Medicine 



The chief character of this work is intended to be essentially 
and thoroughly practical Not for a moment is it intended to allow 
this utillitarian end to escape the mental view. It is the aim to 
point out how to recognize and how to cure disease. Therefore a 
servile adherence to any particular form of classification is not 
important, when a more direct method can be employed. 

1. General Diseases. 
There are certain subjects which bear upon diseases, in general, 
which require consideration, and the methods to be adopted for 
their clinical investigation, before introducing the important sub- 
ject of individual diseases. 



CHAPTER I. 



ON CONTAGION. 

This is a momentous question. It is connected with various 
other maladies, but its chief interest is associated with acute specific 
fevers. Contagion strictly signifies the propagation of disease by 
contact. In a general sense a contagious disease is a disease capa- 
ble of being 'transmitted from one animal, or person, to another, 
either of the same or different species. The agent by which it is 
so transmitted is the " contagion." 

1. Origin and Source of Contagion. — What was the origin of the 
various contagious poisons, and whether they can be produced 
de novo, are questions of no practical importance. Possibly a few 
contagious diseases are thus generated. The mass of these mala- 
dies which claim our careful investigation are transmitted from one 
human being to another. Some are transferred from some animal 



78 CONTAGION. 

to man, as vaccina, glanders, hydrophobia, malignant pustule, etc. 
These can be retransmitted to the same or another animal, in a 
modified form, in some cases. 

Conditions under which it Exists, and Modes of Propagation.. — It exists 
under various forms, and is eliminated in different ways That one 
distinct class of these affections are due to animals or plants and 
their germs, is obvious, as in the various forms of tinea, and 
scabies, etc. It is believed to be associated with various kinds of 
organized cells in other cases, such as those of tubercle, cancer? 
etc. Pus, or other material, is often the agent for conveying the 
poison derived from pustules, or an inflamed or ulcerated surface, 
as in gonorrhoea, syphilis ; glanders, small-pox, and puerperal peri- 
tonitis. It may be contained in vessels, scabs, etc. Many conta- 
gious poisons are exhaled and excreted from the body, especially 
from the skin and lungs without palpable existence ; the breath 
alone is supposed to convey whooping-cough, while others seem to 
exist in all the exhalations and secretions, as small-pox. The 
shedding epithelium furnishes abundant poison in scarlatina. 
Cholera is believed to be conveyed only by the fceces, and typhoid 
fever through drinking water. A special secretion in the saliva 
only can transmit hydrophobia. A contagious poison may be con- 
veyed directly by the blood, and the emanations from the dead 
body of an affected person may produce it in another person, and 
continue to do so some time after death. 

How Transmitted, and how it Gains Access. — Contact of the poison 
with punctured or abrased tissue is sometimes required, so as to 
insure absorption, as in inoculated vaccini. It may occur on an 
ulcer or abrasion, as in hydrophia, syphilis, etc., or without abra- 
sion on a mucous surface, as in purulent opthalmia, and gonor- 
rhoea. Parasitic diseases are propagated by contact, as scabies; 
and malignant pustule by the fluid soaking through the skin. 

What constitutes Infection.-- Many contagious diseases give off 
their poisons into the surrounding atmosphere. These inhaled, 
swallowed, or absorbed by other persons constitute infection. It 
may get into food and drink, as milk, water, etc., and thus infect 
and spread. It may attach to clothes and various fabrics, which 
are termed " fomites,"' and are capable of retaining the poison in 
great activity, for a long period, and thus convey their several dis- 



CONTAGION. 79 

eases to distant places, the poison tends to weaken with the lapse of 
time. 

Persons passing from the sick often convey disease to the healthy. 
Clothes sent to be washed, or sent from an infected school ; or by 
letters, cabs, and numerous other agencies. Furniture, walls, 
floors, curtains, etc., act as " fomites," may infect, often after a 
long interval, when not carefully disinfected. Flies and other 
insects are believed to convey contagion. Drinking-water is 
thought often to contain drainings from excreta and to become a 
dangerous agency for cholera and typhoid fever. 

After contagious poison has reached a person it attaches to the 
skin, mucous membrane of the nose, throat, respiratory, and ali- 
mentary passages, etc., and may penetrate into the air-cells of the 
lungs. It passes through B the thin membranes and imbeds in the 
thick mucous tissue, through which it gradually finds its way into 
the minute interstices between the epthelium cells of the skin. In 
this manner it penetrates the minute capillaries and lymphatics, 
entering them and is conveyed throughout the body. Absorption 
is facilitated by a moist, soft, and swollen skin, or by distended and 
weak capillaries ; by wounds or abrasions, and a relaxed condition 
of tissue, such as the uterus after delivery. 

2. Degree of Contagiousness of Different Diseases. — There are var- 
ious degrees of contagiousness in different diseases. Small-pox and 
others readily communicate typhoid fever ; and others are uncer- 
tain; many modifying influences always attend The contagiousness 
of a disease is in proportion to the quantity and intensity of the 
poison ; a very minute quantity is sufficient in some cases. The 
violence of contagion varies at difterent periods in a disease, or an 
epidemic. 

The mode of application modifies it ; inoculation is obviouslv 
most certain, it being weakened by transmission through successive 
persons; and if largely diluted, it is correspondingly less likely to 
take effect If certain liquids, containing contagious particles 
stand some time, the poison subsides, so that the upper portion 
loses its effect, and the particles may also be separated by thorough 
filtration. The temperament, constitution, state of health, and 
previous habits modify the effect. A previous attack sometimes, 
not invariably, protect against, a second attack, and a second is 



80 CONTAGION. 

usually mild. Two of these affections seldom occur at the same 
time in the same person, and if so, they modify each other ; and in 
some instances, one protects against another, either temporarily or 
permanently, or greatly modifies, as in cow-pox and small-pox. 
Without apparent reason some persons seem quite insusceptible to 
certain infections, possibly having occurred during intra-uterine 
life. 

Unfavorable Irygienic conditions increase the virulence of con- 
tagion. Water is said to intensify the contagion of cholera and 
typhoid fever. Seasons and climates considerably modify some 
diseases requiring a high temperature to develop them, and others 
are checked by great heat. The direct application of great heat 
or extreme cold, and certain chemical agents, are potential in 
destroying contagious poisons, or neutralizing them. Upon these 
we depend, to a great degree, to check the spread of contagious 
diseases. Chlorine, hypochlorite of lime, sulphuric acid, sulphites , 
carbolic and cresylic acids, chloralum, and Condy's fluid, are among 
the best active substances as disinfectants. 

3. Nature of Contagion. — Those diseases due to parasites, the 
special animal or plant is the contagion. As to ordinary infection, 
it is pretty well settled that it is quite distinct from pus, or any 
material with which it may be associated, and which only forms a 
vehicle for the poison. In each disease there is a specific poison, 
capable of producing this one and no other, and without its action 
upon the system it cannot occur. This is named a " contagium," 
"virus," " zyme," or "ferment." 

The chief theories as to the nature of this poison are : 

1. It is a " suttle entity " impossible to detect. 2. It is a 
chemical substance, most commonly supposed to be in the form of a 
volatile gas, and as knowledge improves, may be isolated. 3. That 
it is some "albuminoid matter, in a state of rapid change " causing 
a fermentative or zymotic action in the blood and tissues (hence 
the name "zyme 1 '). 4. The "germ theory" is now most gener- 
ally held, that every contagious disease is due to living germs, each 
specifically distinct from all others. 

As to the precise nature of these germs, opinions are divided 
into two theories. 

1. The majority believe that they are really microscopic para- 



CONTAGION. 81 

sites. Some holding that they belong to the vegetable, and others 
to the animal kingdom, such as minute fungi, vibriones, bacteria, 
etc., or their germs. Bodies of this nature have been noticed in- 
the contents of vesicles, pustules, blood, secretions, excretions, etc, 
in some of the infectious diseases, as vaccini, small-pox, cholera, 
and typhoid fever. These have been termed micrococi, micro- 
zymes, microphytes, microzoaires, etc. 

2. Dr. Lionel Beale argues that the germs are not parasitic, but 
are extremely minute particles of living germinal matter, or bio- 
plasm, which present no differences in appearance in different 
diseases, even under the highest powers of the microscope, but have 
an essential difference in vital power.* 

4. The effects of the action of the " contagion " upon the system 
and the change it undergoes — The results may be local and super- 
ficial, as scabies, and gonorrheoea, or at first local, and subse- 
quently become constitutional, as syphilis. As a rule the first 
action of the poison is upon the general spstem, usually followed by 
local lesions. Attention here will only be called to this last course 
of events as connected with specific fevers 

When the poison of a " specific fever " enters the body, it either 
produces some primary change in the blood, or acts upon the 
nerves, or both. The blood loses fibrin, changes its chemical ele- 
ments; a fermentative or zymotic action begins; the germs rapidly 
multiply at the loss of albuminous elements of the blood, walls of 
the vessels, and tissues. At first there is a period of incubation, 
tolerably definite for each disease, during which there are either 
no s3Tnptoms, or none of any definite character. In hydrophobia 
this incubation may last for months, and that of others is often 
indefinite, but whether long or short, at its close there appears 
mn-e or less severe general symptoms, the onset of which is 
usually well marked by rigors or chills, etc., of a febriale nature, 
and there are often some local symptoms. 

If the poison is intense, and its increase rapid, death may occur 
without structural lesion. If this event does not occur, the local 
disease is manifest after a certain time, which may be limited to 



*Only a mere outline of this subject can be given in this part of the subject. 
Those wishing to pursue this interesting topic are referred to the writings of 
Burdon, Sanderson, Beale, Simon, Guy, and others. 



82 CONTAGION. 

one tissue or organ, or several parts, constituting its anatomical 
characters. The various eruptions in contagious fevers, are im- 
portant local signs of these affections. The symptoms subside after 
a certain period, and if fever existed defervescence occurs, the 
poison ceases to increase and is finally expelled, and structural 
changes may or may not result. There is considerable uniformity 
in the course of the various stages and duration, and in the entire 
affection from the beginning to the end. An acquaintance with 
the " natural history " of each malady is important. Complications 
and sequelae are frequent, which interfere with the natural course- 
Intensity is very various ; some are mild ; others assume a typhoid 
or malignant type, proving very fatal. Epidemics sometimes show 
these peculiar types. 

Elimination of Contagious Poisons. — The various theories are : 

1. The living particles make their way out of the vessels, and 
through the tissues to the surface. 2. They are conveyed out- 
ward, suspended in the fluid which transudes from the small 
vessels. 3. The poison is directly eliminated by the epithelial 
and secreting cells especially those of the skin, kidneys, and intes- 
tines. By this theory the cells attract and separate the virus, and 
are then cast off, and replaced by new cells. The adherents of this 
idea regard the eruptions epithelial desquammation, diarrhoea, etc., 
efforts of nature to eliminate the poison. They base a special treat- 
ment on this idea to assist nature in this " eliminatory " process 
These views are very strongly opposed. Dr Beale argues that the 
cells possess no eliminatory power, but that the poison actually de- 
stroys them, and this is the cause of the shedding of epithelium, as 
observed after scarlet fever. 

On Epidemics. 

The manner in which most diseases are disseminated among 

mankind is naturally divided into three classes, viz : 1. Sporadic, 

those which occur in an isolated and scattered manner, and do not 

affect a large number of people at the same time, as bronchitis, etc. 

2. Endemic, those which are peculiar to some districts, or constant- 
ly prevalent in such districts, more or less, as ague, etc. 3. Epi- 
demics, those which suddenly attack large numbers of people, and 
spread rapidly among them, often producing terrible devastation 
and dismay ; this occurring at regular intervals, as cholera, etc. 



EPIDEMICS. 83 

The term Zymotic now includes all epidemic, endemic, and con- 
tagions diseases which can be prevented by proper attention to 
hygienic and other conditions. Miasmatic is a term applied to 
specific fevers, caused by malarial influences. 

Epidemics are supposed to be produced by some influence, the 
nature of which is, in most cases, quite unknown. An epidemic 
may occasionally be distinctly traced to the influence of contagion, 
aided by unfavorable hygienic conditions, or some obvious cause, 
as famine. Its origin cannot be thus definitely fixed, as a rule ; 
certain maladies occur as epidemics, which are probably not in- 
fectious, as influenza, &c. The facts observed relating to epidemics 
may be briefly stated : 

1. Epidemic influence chiefly affects those diseases which are 
infectious, rendering them more prevalent and dangerous ; or ma- 
larial affections, as those caused by poison due to the decomposition 
of vegetable matter. Only one of these is epidemic at the same 
time, as a rule; sometimes there seems to be a tendency to the 
prevalence of several acute specific diseases together. Sometimes 
other maladies appear to assume an epidemic form, and occasionally 
a new disease appears in this manner. Ordinary diseases, only, are 
sometimes thus influenced, or have a tendency to influence special 
organs. 

2. A prevailing epidemic affects more or less the type of other 
diseases ; thus, choleraic diarrhea is prevalent when cholera pre- 
vails, and catarrhal affections are common during the prevalence 
of influenza. 

3. The extent of an epidemic varies widely. If it is very severe, 
it usually appears in different places in succession, abating in one 
region as it invades another. It may confine itself to a certain 
district, being then usually due to some palpable local cause. 

4. The progress is subject to variations. Generally it is regu- 
larly onward in a certain direction, and in this manner an epidemic 
may make a circuit of the globe. It may make a very rapid 
stride, or proceed very slow and gradual. Epidemics sometimes 
leave a place and then return ; or pass over special regions ; or go 
out of their direct course in a lateral direetion, affecting parts out 
of their proper line of progress. They frequently advance directly 
against the current of winds. 

9* 



84 EPIDEMICS. 

5. The mode of invasion of epidemics may be sudden or less grad- 
ual, usually the latter. An epidemic usually gives indications 
of its approach by some mild form of symptoms, as cholera is 
usually preceded by diarrhea ; or a few sporadic cases may first 
occur, giving warning of its approach. 

6. The. intensity of an epidemic is very various, sometimes ex- 
cessivety fatal, and other times comparatively mild. As a rule, it 
proves most fatal in its early period, and gradually becomes milder 
until it ceases altogether. This may be explained in part by the 
fact that those who first suffer are those most predisposed to it, and 
by the gradual exhaustion of the cause of the epidemic. 

7. The duration of an epidemic is very irregular. It may per- 
sist with remissions, or intermissions, for several years, as has 
cholera sometimes. 

8. Cycles of epidemics have been frequently observed, one disease 
after a certain period being followed by another, and this by a 
third, and so on. Eecently a theory has been put forth to explain 
epidemics ; that there exists what is termed a 'pandemic wave, under 
the influence of which a series of oscillations of febrile diseases occur, 
these following each other regularly over the globe. 

9. The most interesting and important fact is that epidemics are 
largely under human control, both in prevention, and in rendering 
them less severe, by due attention to known hygienic measures, 
which wall next be explained. The advance of civilization has 
already extinguished some epidemics from countries and districts 
where formerly they were excessively rife and destructive In- 
creasing knowledge of the causes and of the proper sanitary anti- 
dotes indicate that many epidemics yet existing will also become 
extinct. 

10. Epidemic influences affect animals, as well as human beings, 
often to a great extent and to a destructive degree. It is not at all 
improbable that j>lants suffer extensive blight from similar influ- 
ences, hence the occasional complete or partial failure of crops in 
wide districts not explainable by the ordinary known causes. 

Hygienic Treatment of Contagious Fevers. — When treating 
a patient suffering with an infectious fever, it is very important to 
prevent its extension to others. This is also highly useful to the 
welfare of the patient. The physician now becomes more an edu- 



HYGIEINE IN CONTAGIOUS FEVERS. 85 

cator than a dispenser of drugs. The chief instructions and 
requisite measures are : 

1. Separation from other persons as far as possible is a necessity, 
and in some cases almost complete isolation. Crowding must be 
prohibited, and only those persons who are required to be in the 
sick-room should be admitted at all. These should wear clothes 
to which contagion cannot easily adhere, and go as little as possi- 
ble among healthy people. Practitioners ought to observe due 
precautions against conveying any contagion themselves, or allow- 
ing others to do so. 

2. Adequate ventilation is indispensible, by opening the windows 
freely, even at night, care being taken to protect the patient from 
draughts. It will not suffice to merely give orders, but show how 
this should be done. 

3. All surplus curtains, bed-clothes, carpets, and other materials 
which can act as "fomites," must be removed. Ventilation is also 
promoted in this manner. Nothing should interrupt the circula- 
tion of pure fresh air. 

4. Cleanliness must be observed in the most scrupulous manner, 
as to the patient, bed, clothing, rooms, &c. 

5. Persons who come close to the patient should avoid inhaling 
the breath, or exhalations, and not afterwards swallow their own 
saliva, but clean out the mouth and nostrils. Thus may the disease 
sometimes be prevented from being taken by visitors. 

6. Disinfection or destruction of everything which may convey 
the contagion. All exhalations and discharges should be immedi- 
ately disinfected. Anything coming off from the skin can be best 
destroyed by frequent sponging with a disinfectant. The room 
should be perceptibly impregnated with a volatile disinfectant, 
such as chlorine, carbolic acid, sulphurous acid, or chloralum, &c. 
A good safeguard is to hang across the doorway a sheet, kept 
moistened with dilute carbolic acid, Condy's fluid, Burnett's fluid , 
or chloralum, Secretions of the mouth and nose ought to be re- 
moved with disinfected rags, and those immediately burned. Ex- 
cretions should be received into vessels containing a disinfectant, and 
mixed thoroughly with it before conveying them from the sick- 
room. This is indispensible when treating cases which are known 
to be propagated by the evacuations, as typhoid fever, cholera, &c, 



86 LIMITATION OF EPIDEMICS. 

and, if possible, convey the stools to a separate closet, and fre- 
quently flood it by a disinfectant, as powder and carbolic acid, 
chloride, or sulphate of zinc, chloride of lime, or chloralum. All 
bed-clothes, clothing, &c, must be put into a vessel containing a 
disinfecting fluid before leaving the room to go to be washed. 
Clothes previously worn by the sufferer must be also disinfected. 
The windows, floor, door, walls, &c , ought to be frequently spong- 
ed with a material to disinfect them. 

7. Any food must not be allowed to remain long in the sick- 
room, and should not be taken in by any one who is not habitually 
in the room. 

8. After the patient has left the room it must be thoroughly 
cleaned and disinfected in every nook and corner, then white-washed, 
or re-papered and painted. Carbolic acid, sulphurous acid, chlor- 
alum, or chlorine, are most efficient for disinfecting unoccupied 
apartments. Heat is very valuable for disinfecting bedding, &c. 

The Prevention and Limitation of Epidemics. 
When an epidemic threatens to invade any place or district, or 
already exists, additional precautions are required in proper hygi- 
enic conditions, and in other measures as well. The uninstructed 
in this regard must be taught what to do, and '-'compulsory educa- 
tion" should be enforced, if need be. Competent persons must be 
appointed to visit every house and see that the proper measures 
are carried out, especially in crowded and uncleanly places The 
chief practical instructions and duties are: 

1. Cleanliness in every particular is indispensible. Premises 
must be frequently washed and white -washed. Prevent all over- 
crowding, and insist upon free ventilation. Look in among the 
poor, and in common lodging houses, and crowded alleys, &c. 

2. Persons who are likely to spread infection must be prohibited 
from mingling with other people, in private or in public, and from 
traveling to other parts. 

3. Decomposing organic matter, especially, house refuse, should be 
promptly removed after having been disinfected, or if this cannot 
be got rid of, mix in it an abundance of disinfectant material. 
House drains and sinks, street drains and sewers, water-closets, 
cesspools, privies, ditches, gutters, &c , require careful inspection, 
and to be kept in good condition. The earth around dwellings is 



PREVENTION OF EPIDEMICS. 87 

often saturated with organic matter, and requires special attention. 
In removing such from around dwellings, it is better for the dwell- 
ers to be away if possible, and thus avoid poisonous emenations. 
Disinfectants must be freely used around houses, and especially in 
filthy localities. 

4. Examine with great care the source of water supply, especially 
that which is used for drinking, and be sure that no organic matter 
gets into it from sewers, drains, cesspools, polluted grounds, &c. 
Waste-pipes from cisterns, opening into drains, must be examined 
to see whether organic matter finds its way into the water. This is 
especially necessary when cholera or typhoid fever prevail. Water 
should always be filtered as a wise precaution. 

5. Healthy people may be removed to a locality out of danger 
of the infection when practicable. It may become necessary to 
carry out a principle of "quarantine" sometimes to stop an 
epidemic. 

6. When there is any known preventive of an epidemic disease, 
this must be resorted to at once and generally, as vaccination, when 
small-pox prevails. 

7. The general health of the people should be fostered and pro- 
moted by every possible means, and all causes that lower the sys- 
tem, as intemperance, or bad habits and ill living, must be avoided. 
Those who attend upon the sick should use every precaution. They 
should dismiss fear, be cheerful, and live upon good nourishing and 
digestible food, without much stimulants. They require daily exer- 
cise in the open air and bright sunlight. They also need sufficient 
sleep, and at proper intervals, observing the most scrupulous care 
and attention to personal cleanliness. 

8. Any one giving the slightest symptoms of the prevailing disease 
should be without delay brought under the proper treatment. 

9. Allow no person who is suffering from an epidemic disease to 
be brought into a locality of healthy people, if it is possible to 
avoid such a calamity. The conveyance of such persons by public 
vehicles is a heinous crime, now punishable by law, in every civil- 
ized land. Special conveyances are provided, when needed, to 
remove them to a pest-house or hospital. When such patients are 
sick at home, isolate them, and in upper rooms, if it is possible 
to do so. 



CHAPTER II 

CLINICAL INVESTIGATION OF ACUTE FEBRILE DISEASES. 

The largest number of diseases which practitioners are called 
upon to treat belong to the class of acute febrile diseases. It is 
essential to have a clear conception of the proper manner of inves- 
tigating the nature and extent of morbid action in each case, and 
that a correct diagnosis be ascertained as soon as possible. The 
special inquiries of the patient and attendants are : 

1. Has the patient been exposed to any infectious disease ? Has 
there been any other obvious cause likely to occasion a febrile con- 
dition, as a cold, exposure to malaria, &c? 

2. Ascertain the exact date, even the hour, when febrile symp- 
toms began ; the nature of them must be ascertained and noted 
with care. 

3. The subsequent symptoms, in detail, must be inquired about, 
and the times when they occurred, and those which now obtain. 
The premonitory symptoms or forming stage of acute specific fevers. 
Certain local symptoms are usually manifested, differing in each case, 
and more or less characteristic. Those which require notice are: 
the existence and severity of general and local pains, as the back, 
or epigastrium, catarrhal, throat, stomach, intestinal, and head 
symptoms. Of course, if the fever is caused by inflammation 
of some organ or tissue, local symptoms will indicate the seat of the 
mischief. 

4. The degree the fever,- or height the abnormal heat has attained, 
is the most important, because it is conceded that the danger in 
acute fevers usually bears exact proportion to the temperature 
above the normal one, also, its course and its mode of progress. To 
determine the temperature the sense of touch is not reliable, as 
this at best cannot be more than approximate, or relative. The 
careful and systematic employment of the thermometer gives pre- 
cision, and materially aids in determining a diagnosis at an early 
period. In the exanthemata the fever is of the "continued" type. 



THE USE OF THE THERMOMETER. 89 

The degree of intensity, and rapidity of onset, foretell the nature 
of the exantheni in many cases, and at an early period. Each is 
understood to have a definite course of temperature, though ex- 
ceptions are observed. 

5. A skin eruption usually constitutes the anatomical characters 
(f special fevers. This rule is not without exceptions. There is no 
cbubt that scarlatina, measles, small-pox, &c, may occur without 
aiy eruption. When due to inoculation, eruption may be confined 
to the spot of introduction. As to the eruption, the points to be 
observed are: 1. the exact time of its appearance; 2. its primary 
sect., and the mode and rapidity of its extension over the body, 
if this occurs ; 3. its amount; 4. its precise characters, and the changes 
it undergoes during its progress and decline ; 5. its duration and 
seqtel. 

6. Careful physical examination of the chief organs of the body, and 
including the urine, is imperative in all febrile diseases. This may 
reveal the cause of the fever even where no symptoms point to any 
particular organ In specific fevers complications are prone to 
arise, )r some organ or organs are primarily affected ; an early de- 
tection of such untoward derangement is very important. Hence 
daily examinations, at least, are requisite, and the principal organs 
more frequently. The sphygmograph is valuable in indicating the 
condition of the circulation of the blood. 

The Use of the Thermometer. 

There is now a generally recognized value of the thermometer 
in the investigation of disease, and it becomes necessary to em- 
phasize the importance of employing it in daily practice, because 
many omh its use to the desirable extent. ' 

The instrument used should be sensitive and accurate, of a suffici- % 
ent range, self -registering, and of a convenient size for carrying in 
the pocket, or what is now generally called a "Clinical Thermome- 
ter,-' and is generally furnished by respectable instrument makers. 

Directions* for Use.' — 1. The Curved Thermometer. — Its bulb must 
be well fitted into the armpit, being introduced below the fold 
of the skin covering the edge of the pectoralis major muscle, and 
so kept in close contact with the skin, completely covered and 
firmly surrounded by the soft parts. In very thin or very old per- 
sons this adjustment requires special care. The instrument must 



90 THE USE OF THE THERMOMETER. 

be retained in situ during a period of not less than four minutes; and 
the height of the mercury in the graduated stem must be read 
while the thermometer is still undisturbed in the axilla, care being taken 
that the axis of vision falls perpendicularly on the column of mer- 
cury in the tube. 

II. The Straight Thermometer, which is self-registering, must hav* 
its index set before commencing to take an observation. 

[N. B — The index is the bit of mercury detached from the colunn 
in the stem of the instrument.'} 

1. This index is to be set by bringing the bit of detached mer- 
cury down into the clear part of the stem, just below the lhes 
which indicate the degrees. This is done by taking the bulb tnd 
stem of the instrument firmly in the hand, and then by a single 
rapid swing of the arm the index will come down the stem ; and 
this swing of the arm must be repeated till the top of the incbx is 
at least below the lines which indicate the degrees. 

2. After the index has thus been set, the bulb of the instranent 
may then be applied to the axilla, or between the thighs, under the 
tongue, or any part which is completely covered ; and being re- 
tained in close apposition (by strapping, if necessary) with tie sur- 
rounding soft parts for a sufficient length of time, the instrument 
is to be carefully and gently removed, when the top of the index — 
i. e., the end farthest from the bulb — will denote the miximum 
temperature during the period the instrument has been in perfect 
contact with the parts. The patient should have been at perfect 
rest in bed for at least one hour before observations on tempera- 
ture are made, and he ought to lie on the side, so as to completely 
close the axillary space, which is the seat of the thermometer, con- 
verting it into a close cavity. 

III. The observations ought to be continued daily, and regular- 
ly taken at the same hour every day, throughout the whole period 
of sickness. The most useful periods for observation are : 1. Be- 
tween 7 and 9 o'clock in the morning. 2. At noon.' 3. Between 
5 and 7 o'clock in the evening. 4. At midnight. For most prac- 
tical purposes, it is sufficient to note the temperature twice daily — 
morning and evening — with an occasional observation at midnight. 

IV. In all observations of temperature the pulse and the respi- 
ration should be noted at the same time. 



CORELATION OF PULSE AND TEMPERATURE. 91 

As a general rule the correlation of pulse and temperature may 
be stated as follows, namely : An increase of temperature of one 
degree above ninety-eight degrees Fahr. corresponds with an in- 
crease of about eight beats of the pulse per minute, as in the fol- 
lowing table: 

A temperature of 98 deg Corresponding with a pulse of 72 (Health.) 

" 99 " Ought to correspond with a pulse of 80 

100 " " " " 88 

101 " " " " 96 

102 " M " " 108 

103 " " " " 112 

104 " " " " 120 

105 " " " " 128 

106 " " " " 136 

This statement is, however, in some respects arbitrary, and is 
given for the convenience of comparing different diseases with 
some standard. In some diseases a high temperature is found with 
a low pulse, and a low temperature with a high or rising pulse. 
The pulse, too, sometimes rises in rapidity when the temperature 
falls, or falls when the temperature rises. 

In children the records are contradictory. For example : Ac- 
cording to the observations of M. Roger, and Dr. Holland, the 
temperature of children is somewhat higher than adults, when 
placed in conditions favorable to sustenance. At birth the tem- 
perature of the infant is the same as that of the mother, but 
quickly falls to 93.4 degrees, or 95.5 degrees, rising in the course 
of twenty-four hours to 97.7 degrees — i. e., more than half a degree 
below adult heat (Maclag&n). Between four and six years of age, 
M. Roger found the temperature to be 98 9 degrees Fahr.; and be- 
tween six and fourteen years, 99.16 degrees (Carpenter). Dr. Ben- 
nett states generally, that in children the heat of the body is about 
two degrees higher than in adults. 

Having satisfied ourselves as to the delicacy and accuracy of the 
thermometer, and obtained a standard for comparison, we are pre- 
pared to appreciate the ranges of temperature in febrile diseases 
as measured by such an accurate instrument. 

The maintenance of a normal temperature, within the limited 
fluctuations just noticed, under all these varying influences, gives 
a complete assurance of the absence of anything beyond local and 
unimportant disturbances; and, long before the subject was work- 
ed out so thoroughly as it has been, it was often casually observed 



92 acute febeilejmseases. 

that any acute disease, however slight, elevates abnormally the 
temperature or animal heat ; <k and its undue degree of elevation 
(as Dr. Davy clearly enunciated) is some criterion of the intensity 
of the diseased action" (Phys. Researches, vol. i, p. 56). In short, it 
is now placed beyond a doubt by the observations of Gierse, 
Roger, Valentin, Von Basrensprung, Wunderlieh, Frielander, Vir- 
chow, Traube, Jockmann, Greisinger, Bilroth and others, in Ger- 
many ; by MM. Becquerel, Breschet and Bernard, in France ; by 
Parkes, Jenner and Ringer in this country, that while this preter- 
natural heat varies in amount in different diseases, in different per- 
sons, and at different timea of the same day, it is this preternatural 
heat which is the essential symptom in fever, which proves fever to 
be present, and which exists to the extent of four, six, and even 
eight degrees Fahrenheit over the natural limits of health, and 
must be estimated by the temperature in the axilla or rectum, as 
indicated by the thermometer. This preternatural heat is never 
absent in fever, and without it fever cannot be said to exist. Rigor, 
which is also sometimes present, is a mere peripheric phenomenon. 
The coldness of the skin, so much complained of by the patient, is 
usually a subjective sensation, produced by the state of the per- 
ipheral nerves, and is not due to any actual decline of temperature ; 
for even "while the outer parts feel cold to the bystander, the inner 
parts are abnormally warm. While the outer parts freeze, the 
inner burn," (Virchow, Parkes, Jenner). 

When the temperature is increased beyond 98.5 degrees or 99 
degrees, it merely shows that the individual is ill, and suffering 
from some disease ; and that when considerably raised, as with a 
temperature of 101 to 105 degrees Fahr., the febrile phenomena 
are severe ; that when a great height is reached, as at temperatures 
above 105 degrees Fahr., the patient is in imminent danger ; and 
that with a rising temperature above 106 degrees Fahr., to 108 or 
109 degrees Fahr , a fatal issue may almost without doubt be ex- 
pected in a comparatively short time. The highest temperatures 
before death have been observed in cases of scarlet fever and 
of tetanus. 

A decrease of temperature below the normal is rare. It happens 
sometimes transitorily, announcing thereby a favorable crisis, by 
preceding the return to a normal temperature. It is also met with 



ZYMOTIC DISEASES. 93 

sometimes during the morning remission of remittent fevers ; also 
during the apyrexia of intermittents ; in acute collapse, preceded or 
not by fever ; in chronic wasting diseases ; and sometimes, also, on 
the approach of death, especially in typhus fever, in which the car- 
diac symptoms have been dangerous. — Aitki?i. 



PART II. 



INDIVIDUAL DISEASES. 

Zymotic Diseases. 

Zymotic Diseases, or maladies that are either epidemic or con- 
tagious, induced by some specific poison, or by the want of food, or 
by its quality. 

CHAPTER I.— Order 1. 

Variola. 

Synonym. — Small-pox. Varieties. — Discrete and confluent; 
also, varioloid or modified small-pox, after vaccination. 

Symptoms and Course. — Stages: These are, incubation, primary 
fever, eruption, secondary fever, and desquamation. The incuba- 
tion (period between exposure to the contagion and beginning of 
the attack) lasts about twelve days. The first symptoms are lan- 
guor, headache, vomiting, and severe pain in the back ; soon de- 
veloping into fever. On the third day of this, pimples, at first 
small and red, appear, first on the face, then on the neck, arms, 
trunk, and lower limbs. These papules become vesicles and then 
pustules ; suppurating perfectly by the ninth day of the fever. 
Then they flatten and scab. Four or five days later, about the 
fourteenth day of the fever, these scabs begin to fall off. Desqua- 



94 VARIOLA. 

mation is commonly completed by the end of the third week of the 
attack To recapitulate : there are, after about twelve days of in- 
cubation, three of primary fever, six or seven for the coming out 
and maturing of the eruption, four or five for its scabbing, and six 
or seven for desquamation. 

These periods vary somewhat. The severity of the disease de- 
pends mostly upon the amount of the eruption. This makes the 
difference between the discrete (scattered, separate) and confluent 
small -pox. Even the primary symptoms are generally worse in the 
latter. The secondary fever, connected with the full development 
of the eruption (about the eleventh day of disease), is much the 
most severe in the confluent. The suffering of the patient is great, 
even extreme, in this form, the whole surface of the body being 
covered with inflamed pustules. Even the eyes, mouth, and throat 
may be invaded. Blindness sometimes follows. A peculiar and 
disagreeable odor emanates from the body in confluent cases. 

Malignant small-pox is simply a violent form of it, characterized 
by rapidity, and extreme prostration, with or without extensive 
pustulation. The eruption, in it, is sometimes attended by lividity 
of the skin. Delirium is common, and a typhoid stupor may exist. 

After small-pox, abscesses in various parts of the body, hard 
glandular enlargements, ulceration of the cornea, suppuration 
of the ear, pneumonia, or pyaemia may occur. 

The danger to life in this disease is liable to be serious. Before 
vaccination, thousands died annually from small-pox. 

Causation. — There is no disease more certainly contagious than 
variola. Generally either contact or approach within a few feet 
seems necessary for its conveyance. In the large majority of cases, 
small-pox occurs but once in a life-time. Exceptions are well 
known, however ; some in which the same person has had it twice 
or more. 

Treatment. — The fever calls : 1. for a cooling laxative dose, as 
Rochelle salt or citrate of magnesium. Then, refrigerent diapho- 
retics are proper; as a neutral mixture, effervescing draught, or 
liquor ammonia acetatis. No cutting short is possible ; it is a self- 
limited disease. No specific remedy has been found for it ; we can 
greatly palliate it only ; support the system and conduct the pa- 
tient safely through the disease. 



VARIOLA. 95 

So decidedly is the tendency to exhaustion of the system, in 
severe small-pox, that early support by concentrated liquid nour- 
ishment must be the general rule. Milk, cream, &c., in small 
quantities, often (one or two table-spoonfuls every two or three 
hours), and chicken or mutton soup, or beef tea, and similar food, 
must be given. These may be alternated by other diet for the 
sick, as gruel, arrow-root, toast-water, &c , especially during the 
early fever. Many cases will require early stimulation, or as soon 
as the second or third week, as wine, whey, or whisky punch ; per- 
haps malignant cases, and persons of intemperate habits, may re- 
quire stimulation in the first week. Quinine or cinchonidia, in 
tonic doses, should be given with stimulants, one or two grains 
every three or four hours. An anodyne, or nervine, at night is 
often required. 

To prevent pitting of the face and neck is very important. There 
are various plans to accomplish this : 1. To abort the vessicles by 
puncturing them, and letting out the fluid on the fourth and fifth 
day; then touch each with the point of a pencil of lunar caustic, 
after which annoint with olive oil. Next day sponge with a warm, 
weak solution of borax in warm soft water, and renew the oil twice 
daily until healed. 2. Soothe the inflammation with a soft emolli- 
ent poultice over the whole face during the first week. 3. By ex- 
clusion of air and light by a soft ointment, or collodion, softened 
by adding 5 oth part of glycerine before painting it upon the face. 
I greatly prefer the first or abortive process, and this seldom re- 
sults in pitting. 

The sequela of small-pox must be treated as they occur, by open- 
ing abscesses, improving the tone of the system by tonics, as iron, 
&c. Extremes of temperature must be avoided. There is great 
danger of pneumonia, pleurisy and bronchitis from a sudden cold. 
The reader is referred to the directions in the last chapter for the 
proper management of acute infectious diseases, and which must 
be strictly observed in small-pox, one of the most contagious of all 
maladies. 

The general plan of treatment has been marked out, but special 
symptoms require further notice, as vomiting, diarrhre, restlessness, 
or sleepiness, delirium, very sore throat, and hemorrhage. The 
first two require the ordinary remedies. If there exist bronchial 



96 VARIOLA. 

catarrh, no opiates are admissible. A full dose of bromide of pot- 
ash is proper every night to secure rest, until the patient gets in 
the habit of sleeping. Nourishment and stimulents generally allay 
the delirium when it is troublesome. There are exceptions, which 
may require the use of chloral ; nepenthe in whisky-punch ; the 
warm bath, &c. Sore throat is best relieved by a mild gargle, and 
sucking ice frequently, or taking frequently of a little currant 
jelly. Hemorrhages require tanic or galic acid ; turpentine, or 
ergot, separately or in combination, and the free use of the tinc- 
ture of steel, or mineral acids and chalibeates. If the retention 
or suppression of urine occur, the catheter must be used, for the 
former ; fomentations over the loins and diuretics to arouse the 
renal secretion, in the latter. 

Complications are numerous in small-pox, and every precaution 
should be exercised, especially those of the organs of respiration, 
the eyes, and of abscesses. If bronchitis occurs, inhalations, and 
encourage the patient to cough and expectorate freely. Abscesses 
must be promptly opened. Purulent discharges require strict at- 
tention to cleanliness, with the free use of antiseptics. If inflam- 
mation occurs in the eyes, poppy fomentations with alum are ex- 
cellent. 

The treatment of small-pox with antiseptics has received great 
attention, and the weight of opinion is in its favor. Carbolic acid, 
sulpho-chlorites, sulphurous acid, sulphites, or hypo-chlorites, are 
employed, in connectien with tonics, as quinine, iron, &c, and this 
course is reported to have been very successful. During conva- 
lescence, after severe cases, good diet and tonics are requisite, and 
warm alkaline baths should be daily used until the usual health is 
recovered. 

Preventive Treatment. — The rules to prevent the spread 
of contagion are indispensible. Patients recovering should not 
mingle with the healthy until fully recovered and thoroughly dis- 
infected. When small-pox appears on shipboard, or among a lot 
of people in a confined space, and no good vaccine virus can be 
obtained, it would be proper to put all who are liable to it on 
proper diet and regulations, then vaccinate them with the real 
variolous matter in order to secure a modified or mild type of the 
disease, as was the early custom among the parents of many of us 



VACCINATION. 97 

who are still living. I well remember this practice, and when few 
would believe in or trust to vaccine virus. Few, indeed, who pur- 
sued this course, suffered much from the effects, nor were they 
often even "pitted," and no mortality resulted. 

Varioloid: Modified Small-pox. — In those who have been vacci- 
nated, while the liability to be affected by the virus of small-pox 
is in most cases removed, in a few the disease is taken on exposure, 
in a milder form. The primary fever is rather less severe, the 
eruption is more scattered, the pustules are not so deep nor so 
much inflamed, they scab sooner, and very rarely pit ; and there is 
no secondary fever. Varioloid is seldom fatal. Its treatment 
should be essentially the same as that of small-pox ; only there is 
less often need of special measures to prevent marking of the face. 

Vaccination. 

The ancient practice of inoculation with small-pox, while it was, 
by the mildness of the attack, nearly always protective of the in- 
dividual, at the same time propagated the disease, multiplying the 
amount of its virus. Jenner's introduction into professional prac- 
tice of inoculation with the virus of cow-pox, known before his 
time among dairymen, has greatly abridged not only the destruc- 
tiveness, but the prevalence of variola. 

Whether "vaccinia," or cow-pox, is small-pox affecting the cow, 
or is a different disease whose virus is protective against small-pox, 
is not yet determined to the satisfaction of all investigators. Ex- 
periments have been tried repeatedly, with conflicting results. 
Either way, the facts are plain, that most persons are, by one good 
vaccination, protected for life ; that modified small-pox, occurring 
in the vaccinated, is very seldom indeed fatal, and hardly ever pits ; 
and that repeated vaccination, after an interval of years, will make 
protection almost always complete. 

Vaccination may be performed either with the fresh lymph, the 
same dried by keeping, or the scab ; and, either directly from the 
udder of the cow, or from a human being inoculated with cow-pox. 
In Europe the lymph of the vesicle, before maturation, is gener- 
ally preferred. In this country the scab is much used, and is 
found reliable, when fresh enough. No matter how it is kept, after 
a month it is uncertain; although it has sometimes been found 



98 VACCINATION. 

efficient after being sealed up for a year ; especially when mixed 
with glycerine. 

Direct inoculation from the cow often makes a very sore arm, 
with considerable fever. For infants, unless rugged in health, this 
is an undesirably severe process. It is, at the same time, probable 
that many transits through human bodies may somewhat modify 
the virus. Renewal, by inoculating healthy children, not too 
young, every now and then, from the udder of the cow, is to be 
recommended. Cattle with the cow-pox may be found in almost 
any agricultural neighborhood. 

In the absence of small-pox, the second month of infancy will be 
time enough for vaccination. But under danger of exposure, a 
babe should be vaccinated at"; any time after birth. Matter only 
from healthy children ought ever to be used. While it is unlikely 
that any constitutional disease (as syhilis* or scrofula) can be so 
introduced, there should, in practice, be no room left for any doubt 
of the kind ; and some cutaneous diseases might certainly be trans- 
mitted Unless on account of risk from exposure, the existence 
of an eruption on the skin, or any other indisposition of the child 
itself, may be a reason for postponing the operation. The excite- 
ment produced by it may aggravate an existing imilammatory affec- 
tion. Vaccination has often been blamed for the breaking out 
of eruptions, supposed to be transmitted, when their cause was 
really the state of the system of the patient. 

For the operation, the outside of the arm near the shoulder is 
commonly selected. The exact method used is not important. A 
small, wedge-shaped lancet, or even a sharp-pointed penknife, will 
do. Various slides have been contrived for the purpose. I prefer 
to cut or push out a very small flap of cuticle, under which a thick 
paste, made by pressing and mixing a portion of the scab with a 
drop of tepid water, may be inserted. The art of the operation is, 
to pierce the skin without drawing enough blood to flow ; it is 
most successful when there is no blood at all. Besides the flap, it 
is as well to scratch the skin, and puncture it, at a little distance, 

* In Italy, western France, and elsewhere, a great number of cases of Syph- 
ilitic disease (primary and secondary), following impure vaccination, have 
been reported. Extreme caution is imperative in the selection of vaccine 
matter. 



VARICELLA. 99 

giving three chances of taking instead of one. No disturbance 
of the arm must be allowed for twenty minutes or half an hour 
afterwards. 

If it be successful, no sign of it is distinctly visible for two or 
three days. On the fourth day a decided, small red pimple is to 
be seen and felt. This becomes a vesicle of some size on the fifth 
day ; it grows large and cylindrical, or hat-shaped, and by the 
tenth or eleventh day is fully umbilicated, or depressed like a navel 
in the center. Before that, about the eighth day, the bright red 
ring or areola forms around it. This fades after the eleventh day, 
and the vesicle dries up into a round and flat, but rather thick, 
mahogany-colored scab, which falls off about the nineteenth day. 
All of these particulars are important, as showing the genuineness 
of the vaccination. So is the appearance of the cicatrix left ; 
which should be large in proportion to the vesicle, and dotted or 
marked \vith subdivisions. This is owing to the vesicle being com- 
posed of several small cells or compartments. 

Slight fever, with restlessness, is not unfrequently observed dur- 
ing the first few days after the vesicle appears ; but there is rarely 
anything requiring treatment. 

Re-vaccination— Experience shows that a small number of per- 
sons, after several years, reacquire the susceptibility to small-pox. 
As the only test of this is exposure either to the latter or to vac- 
cinia, the renewal of the latter, at least once after puberty, is 
always advisable. On the occasion of epidemics of small-pox, it 
may be repeated again and again. There is no pain of any conse- 
quence in this operation, nor danger, and, if a genuine vesicle 
forms, making a sore arm, that discomfort for a few days cheaply 
purchases immunity from the terrible disease. Certainly small-pox 
is extremely rare in re-vaccinated persons. 

The virus from a second vaccination should not be relied upon 
for use. 

Varicella. 

Synonym.- -Chicke7i-pox. This is a mild exanthematous disease 
resembling small-pox or varioloid considerably. After an incuba- 
tion of four or five days from exposure to the contagion of one 
having it, pimples form, generally scattered widely. In the second 

day they become vesicles filled with lymph. Two or three days 

10* 



100 SCARLATINA. 

more find them scabbing ; they dry and fall off soon, without pit- 
ting except in rare instances. There is little or no fever or other 
indisposition. The disease is attended with no danger to life, and 
requires only precautionary treatment, i. e., to avoid exposure to 
cold and wet, to keep the bowels regular, and, if needful, promote 
action of the skin by a diaphoretic, as neutral mixture. 

The eruption of varicella differs from that of variola in coming 
out in successive crops ; in not suppurating or becoming umbili- 
cated ; and in not deeply involving the true skin. 

Scarlatina. 

Synonym. — Scarlet fever. 

Varieties. — Scarlatina simplex, anginosa, and maligna. 

Symptoms and Course. — After an incubation, supposed to be 
about five days after exposure to its cause, lassitude, anorexia, 
headache, and pains in the back and limbs mark the beginning 
of the attack. Soon these are followed by fever ; on the first day, 
very often, the throat is sore. On the second day, usually, a 
punctated red eruption appears on the face and neck, and in ten 
or twelve hours has covered the whole body. It is of a scarlet, or 
sometimes a brick-red hue, uniformly diffused, with a swollen ap- 
pearance, and great heat ; reaching by the thermometer even 106° 
Fahr. Occasionally miliary vesicles are seen. There is also a 
sense of burning and some soreness or irritation of the skin. The 
tongue has a strawberry-like look, from the projection of enlarged 
red papillae through a whitish fur. The throat is very red and 
swollen, generally with a hue not unlike that of the skin. Fever 
runs very high, with an extremely rapid pulse, great thirst, head- 
ache, perhaps delirium, costiveness, in some cases vomiting. Bad 
cases may have stupor. By the fifth day mild examples of the 
disease show already an. abatement. Most have passed the height 
of the pyrexia by the ninth; although sequeke may protract the 
attack much longer. Malignant cases may be fatal in a day or 
two, or even in less than twenty-four hours. Desquamation of the 
skin follows the fading of the eruption ; often large masses of cuti- 
cle coming away at once. At this stage more or less decidtd albu- 
minuria is common. 

Scarlatina Simplex. — In this the eruption comes out early and 
well, with moderate fever, little inflammation of the throat, and 



SCARLATINA. 101 

an even course throughout. Somestimes there is hardly any febrile 
disturbance ; and the child may play about without having to go 
to bed. 

Scarlatina Angirtosa. — Here the violence of the disease falls upon 
the throat chiefly. The tonsils swell greatly, suppurating either 
early or late, or they are covered by pseudo-membranous deposit, 
white, gray, or dark brown, whose coming away leaves an ulcerous 
surface, with in some instances an acrid, offensive discharge, The 
extension of the ulcerative inflammation may pass the Eustachian 
tube to the tympanum, and even may destroy the auditory appa- 
ratus so as to cause permanent deafness. After the rash has dis- 
appeared, abscesses in the neck may form and discharge, exhaust- 
ing the patient. 

Scarlatina Maligna. — This term designates an overwhelming tox- 
emic impression of the morbid cause of the disease. Depression 
in the first stage becomes intense, without reaction ; or, after the 
eruption has partly come out, it recedes, or grows livid in appear- 
ance; or the brain is oppressed with coma. Coldness is sometimes 
present, or unequal temperature of different parts of the body, 
instead of the usually diffused febrile heat. The throat may be 
much or little affected. In some instances the patient seems almost 
as if struck by lightning — so sudden and deep is the general pros- 
tration. In this condition death may take place in a few hours. 
Otherwise, with continued prostration, hemorrhage from the stom- 
ach or bowels, vomiting, or diarrhea threatens an untoward result. 

Sequelae. — Abscesses about the throat have been mentioned : 
similar local affections may take place elsewhere after the attack. 
Ozcena is not uncommon ; neither is suppurative inflammation 
of one or more of the joints, or of the testicle ; nor vaginitis. En- 
docarditis or pericarditis may occur. So may paralysis; either 
hemiplegia or paraplegia ; generally it is partial, and it is often 
slowly recovered from. 

Dropsy, from arrested action of the kidneys, with imperfect 
action of the skin, is the most common and in many cases the most 
serious of the sequelae of scarlatina. It comes most frequently 
within a week or two after desquamation has commenced. Mild 
cases are almost as likely to be followed by it as severe ones. Ex- 
posure to cold is the generally observable direct cause ; but cases 



102 SCARLATINA. 

happen in which no such exposure could have existed. Anasarca 
is the least dangerous though most frequent form of this dropsy. 
They may, instead or in addition, be ascites, hydrothorax, or hydro- 
cephalus. Albuminuria, and often hematuria, accompanies either 
form. 

Diagnosis.' — From measles scarlet fever is known by the erup- 
tion coming out on the second day, without catarrhal symptoms 
but with sore throat — and by its being of a brighter red color, and 
uniformly diffused instead of being in patches, like measles. 

From roseola, it is distinguished by the fever and sore throat, 
and by the rash in the latter, being in irregular blotches, damask 
rose color instead of the brick or scarlet-red hue. 

Prognosis. — This is proverbially uncertain in scarlet fever. The 
simple form is, however, the least dangerous, and a very large 
majority of cases get well. The anginose is more threatening and 
serious. But the malignant variety, as its name indicates, is far 
the most so ; recovery from it is the exception, although it does 
occur. Adults are, when affected with scarlet fever, in somewhat 
greater danger than children ; and so, especially, are puerperal 
women. 

Causation. — Although most (not all) authorities agree that this 
disease is very contagious, it is certainly very capricious or 
variable in its manifestation of this quality. That is, many per- 
persons who are exposed escape it. It is true, that several children 
in a family often have it in immediate succession. But the escape 
of all but one is common. It rarely occurs twice in the same 
person. 

Histology. — Scarlatina manifests great diversity in the organs 
which it affects by preference ; and of intensity in individual cases 
in the same family, and through an entire epidemic. 1. It mani- 
fests a peculiar hypersemic exanthera of more or less diffusion over 
the entire surface of the body. 2. An angina at an early period 
and of very variable intensity. 3. Certain phenomena in the 
joints, serous membranes, kidneys, and subcutaneous cellular tissue, 
are most prominent characteristics. The entire disease is the ex- 
pression of an infection of the entire body by a specific contagion. 
Dr. Morton first established its specific nature in the great epi- 
demic in London from 1661 to 1675, thus laying the basis of our 



SCARLATINA. 103 

positive knowledge of scarlatina, which numerous observations 
since have materially extended. It is a singular fact, that this 
disease, unlike most epidemics, becomes more intense throughout 
the civilized world. Commerce seems to be a main extending 
medium. 

Like other epidemics caused by contagion death may occur in a 
brief space, and it may be modified to any degree of mildness, ac- 
cording to individual susceptibility, or producing no effect on many, 
owing to their being impervious to it. It has been proved that 
milk can receive and convey the poison, as also can some other 
fluids. Unaffected persons who are briefly exposed may convey it 
on their apparel, and otherwise. The period of incubation after 
exposure to the cause, is settled as an average of from four to seven 
days. The individual predisposition to scarlatina is much more 
general than that to measles and variola, and in no respect iden- 
tical. This predisposition diminishes with increasing age, as a 
rule. The season most liable to this epidemic is shown in round 
numbers by Centman's statistics, gathered from all countries, viz : 
120 in winter, 80 in the spring, 90 in summer, and 100 having oc- 
curred in autumn. The variable character of these epidemics is 
determined by local causes, and not by atmospheric temperature, 
as the above shows. 

Treatment — 1. Isolation is an indispensable prophylaxis. Where 
this is impossible, all unnecessary articles must be removed from 
the sick-room, and all things which can collect or retain dust; free 
ventilation from out doors, or the next room, as weather permits, 
while the patient is protected from currents of air. Cleanliness 
of patient and apartment must be strictly observed. Expectora- 
tions, urine and excrements must be received in disinfected vessels, 
and promptly removed ; the sick chamber often renovated and 
abound with proper disinfectants, (chlorinated lime, carbolic acid, 
bromo-chloralum, etc.), in the proper form. The patient's linen 
when changed should be placed in these solutions. Pieces of old 
linen should supply the use of handkerchiefs, and be burned daily. 
The necessary attendants should observe similar prudence, and no 
others allowed admittance. 

The symptomatic is the rational treatment for scarlet fever. The 
disease tends to recovery, provided the fever and local symptoms 



104 SCARLATINA. 

are kept within certain limits. We should watch with the utmost 
care to detect any anomaly, and promptly render the necessary 
aid. During the uncomplicated course of scarlet fever, the patient 
should remain in bed from the beginning to the completion of des- 
quamation. The covering should be neither too light, nor heavy 
and oppressive. The temperature of the room should be uniformly 
59° Fahr., unless some few cases of over sensitive patients com- 
plain of feeling chilly, from the decrease of fever, when warmth is 
needed. Special attention to the skin is requisite ; sponge the 
body frequently with tepid water, to which add a little borax and 
carbolic acid. This will soften and cool the congested skin, allay 
the itching and burning, and act as a disinfectant. 

During the angina, use a slightly astringent gargle and rinse the 
mouth with some cleansing fluid. Lemonade and water are proper 
to drink. During the height of the disease the diet may consist 
of milk, cream, buttermilk and soups. As soon as it begins to de- 
cline the patient should receive good substantial nourishment. 
The bowels should be regular throughout, aided, if required, by 
enema or a mild saline aperient. Desquamation must be complete 
before the patient is allowed to move about, to evade the danger 
of nephritis supervening. The urine must be earefully examined 
to early detect and prevent this dangerous sequel of scarlatina. 

The hydrotherapeutic treatment, modified to suit the phases 
of this fever, conforming strictly to its tolerance by the patient, is 
conceded to be the best. It should be energetically practiced only 
when the fever runs high, and modified in proportion to the nature 
of each stage and case. Nephritis seldom occurs after hydrother- 
epeutics have been appropriately practiced, and the skin has had 
proper care. Internally, little medicine need be given in ordinary 
cases. # Tinct. aconite gtt. x, syr. ipecac 3i< spts. nit. dulc. 3iss, 
syr. simplex 3iss, carbolic acid grs. ii. One teaspoonful every 
three hours is obviously proper, as long as required, for adults. 

Anomalous and complicated cases. — Whenever a high febrile condi- 
tion persists, assuming a constant character, we may be sure that 
a corresponding extreme of exhaustion will supervene, which may 
occur suddenly. During such a high grade of fever anomalons 
swellings of the organs about the throat are apt to occur, causing 
diincult deglutition, etc. Discutient ungents over submaxillary 



SCARLATINA. 105 

glands and the cold pack are required. Nourishment must be 
given and the system sustained, though appetite is wanting ; cold 
cream frequently given yields the most nourishment and soothes 
the throat best ; sucking pieces of ice to allay thirst and cool the 
mouth and throat is proper. Sometimes camphorated lotions, hops 
or other warm anodyne fomentations, are better applications to the 
throat than the cold pack, especially in feeble, sensitive patients. 
Occasionally quinine in full doses every four hours, is indicated 
and yields good results. When the tonsils rapidly enlarge and 
threaten suffocation, scarify them freely. In gangrenous affections 
of the throat, permanganate of potash, fifteen grains to an onnce 
of water, is a good gargle. Other deodorizing gargles, as carbolic 
acid one part to two hundred of water, chlorine water, a solution 
of chlorate of potash, are proper to alternate. Ulcers should be 
cauterized. 

Complicated with diptheria should be treated same as diptheria. 
If the nasal fossae are implicated, the membrane should be removed 
by a solvent or mechanically. In simple coryza, or purulent ulcer- 
ative coryza, similar treatment is proper. 

In children the nares should be regularly cleansed and oiled. 
Stomatitis also often requires special attention, and must be treat- 
ed on general principles. Diseases of the ear require early and 
efficient special treatment. The lower portion of the Eustachian 
tube must be cleared by means of douches, gargles, etc. Some- 
times the external auditory canal requires artificial opening, if no 
spontaneous opening occurs. 

The occurrence of bronchial or pulmonary complications require 
constantly renewed, pure air. It strengthens the respiration, pro- 
motes expectoration and alleviates dyspnoea. The heart's action 
must be stimulated an domain tained. Anti-ferbrile measures, care- 
ful use of expectorants, and fomentations to the chest are in- 
dicated. 

Intestinal disturbances, generally diarrhea, do not require other 
than dietetic measures. Eheumatism of the joints is generally 
of a mild form; alkalies internally and externally, and rest, usu- 
ally allays the rheumatic trouble. Endocarditis in scarlatina re- 
quires continual application of cold to the precordial region, abso- 
lute rest, and digitalis to lessen the great frequency of the pulse. 



106 SCARLATINA. 

Hemorrhagic scarlet fever indicates the use of anti-miasmatic and 
anti-ferbrile means and measures; quinine, hypo-sulphites, car- 
bolic acid, and salicylic acid; cold, locally applied, to arrest severe 
hemorrhage. Stimulents and generous diet are usually needed. 

Severe brain symptoms are generally due to the high grade of fever, 
and the specific poisoning, and will generally yield to active anti- 
febrile treatment. Congestion, incipient meningitis, etc., require 
energetic measures, cold to the head, evaporating lotions, etc.; or 
if simple brain excitement, nervous delirium, derivatives are indi- 
cated during and after defervescence. 

Cervical cellular inflammation, if severe, with or without lympha- 
dentitis, requires cold dressings until suppuration is apparent, then 
change to warm applications. Abscesses must be promptly open- 
ed, to guard against burrowing, erosion of blood-vessels, and de- 
struction of important nerves. Disinfectants must now be freely 
used, and openings be well and frequently cleansed and protected 
with antiseptics. 

Nephritis is most liable to occur. Its intensity may be frequently 
modified by warm baths, fomentations to the loins, and general 
measures favoring diaphoresis. Hemorrhages from the kidneys will 
mostly also yield to these simple means, without hypodermic injec- 
tions of ergot If patients are very weak, the vapor bath should 
be used instead of the water bath, and skin action kept up. Dia- 
phoresis may be aided by mild diuretics, juniper, onions, acetate or 
citrate of potash, lemon juice, iodide of potassium, etc., and alka- 
line salts ; by their use, with freely drinking water, urinary secre- 
tion is promoted, and absorption of dropsical effusion is hastened. 

If, in spite of every eftort, albuminuria and intestinal catarrh 
persist, and an excessive accumulation of dropsical fluid gathers in 
either of the serous cavities, tapping may be required. In a high 
degree of anasarca, scarifications are proper ; the dressing of the 
wounds should be soaked in a solution of carbolic acid, to insure 
a healthy action. Eclamptic or uremic symptoms sometimes obtain 
during dropsy. These with active convulsions must be subdued by 
inhalation of chloroform and ether aa.; then continue warm or 
vapor baths, strict quiet, tonics, as iron, etc. 

This very brief sketch of scarlatina in its varied forms and com- 
plications gives only a general idea of the disease and treatment. 



DIPHTHERIA. 107 

I have taken an active part in many scarlatina epidemics, employ- 
ing these general means and measures ; a very small mortality, and 
little unfavorable sequelae have resulted, in my own experience. 
In my opinion, this malady receives too much medication, as a 
rule. This is a morbid condition that requires supporting meas- 
ures; favorable conditions and surroundings. There are no known 
prophylactics. 



DIPHTHERIA. 



This term is derived from a Greek word, which means a skin or 
membraie. 

Synofvms. — Pseudo-membranous Angina; Angina Maligna; 
Cynanck Membranacea; Putrid Sore Throat ; Malignant Quinsy ; 
Diphtheritis. 

The fa-egoing expressive terms indicate the principal character 
of this aarming malady. 

Histoiy. — This disease appears to have been described by early 
writers, ind is one of the oldest epidemics of our race, though the 
name b} which it is now recognized — Diphtheria (a skin or mem- 
brane)— was only given to it by Brettoneau of Tours about forty 
years ap. Late epidemics of it have been principally those of 
Holland.Paris and Boulogne of 1855-7, passing to England in the 
latter ye,r ; and of our own country, beginning in California in 
1856, ari in the Eastern States a little later, and gradually in- 
creasing n prevalence until 1860. Since that date it has declined 
in frequeicy until about 1875, since which it has been on the in- 
crease in lany large cities and districts up to the present time, and 
sometimes^ttended by great local mortality. 

EtioloG'. — The most important question in this whole subject 
is that conerning the relation of certain vegetable organisms to diph- 



108 DIPHTHERIA. 

theria ; whether their unfailing presence is determined by accident 
and by a soil favorable to their growth, such as the products of the 
disease afford, or whether they stand in -casual relation to the diph- 
theritic process, this involves the nature and character of the 
diphtheritic contagion, and of which we know as little as of the 
nature of malaria. Dr. Ortel gives an exhaustive investigation 
of this whole subject in his extended paper on diphtheria in Ziems- 
sen's Cycloptedia, and reaches important conclusions. 

1. It is known to have prevailed epidemically not only at all 
times of the year, but also under the most variable atmospheric 
conditions, and therefore unlike all known malarial forms of disease. 

2. The extensive statistics of Wibner show greater prevalence 
of the disease during the winter, especially its mortality, than at 
any other season of the year. Precisely the reverse would be the 
result if diphtheria is due to malaria. 

3. That without the presence of certain vegetable organisms 
(micrococci) there can be no diphtheritic process. They are found 
in the very smallest and most superficial plaques ; in imnense col- 
lections in the tissues ; in embolism as the cause of metastatic ab- 
scesses ; and that the intensity of toxic infection increases in pro- 
portion to the number of these organisms. 

4. What way bacteria act ; whether they consume the Ife of the 
blood and tissues, inciting simultaneous decomposition and new 
combination of molecules; whether all the products of assimila- 
tion remain shut up in the bacteria themselves, as do the insoluble 
pigments, or are thrown out again like soluble. colorin| matters; 
or whether they form in the blood, like acetic acid in alohol, and 
produce a toxic action like pepticin, so that the special action 
of the fluid of organic substance in which micrococci vegetate, 
passes over into them ; whether, finally, these organisms play the 
part of a ferment of oxidation or reduction — all these poiits, in the 
present state of scientific knowledge, must be left undtermined. 
(Compare Cohn). 

Period of Incubation.— The time which elapses btween the 
moment of the diphtheritic poison coming in contact wih the body 
and that when the development of the poison becoms both sub- 
jectively and objectively appreciable is variously statec 



PERIOD OF INCUBATION. 109 

1. It depends on the quantity and quality of the infecting ma- 
terial. 

2. Upon -the power of resistance, as well as the structure and 
texture of the tissues, which permit the penetration and absorption 
of the diphtheritic poison with varying facility. 

The action of this matter begins the moment it comes in contact 
w T ith them. In like manner the reaction of the tissues begins with 
the earliest irritation, but the changes in the diseased tissues, of 
sufficient extent to be readily recognized, and the appearance 
of constitutional disturbance, as fever, and excitement immediately 
followed by prostration, are not accomplished until these processes 
have reached a certain degree of intensity and involved a sufficient 
extent of texture. 

Therefore, the point of time which closes the incubation, and at 
which we date the attack, varies with the intensity and amount 
of the poisonous matter and the power of resistance. These are 
more active during the prevalence of an epidemic Experiments 
by Prof. Bartelo and Dr. Kardel, by inoculation, proved that the 
wtage of incubation or latent course of diphtheria lasted from two 
to five days. In most cases the period is short. 

Varieties. — 1. Simple ; 2. croupous , 3. ulcerative ; 4. malig- 
nant. It is important to become familiar with this disease in all 
its distinctive features and phases. 

An epidemic and contagious sore throat of great severity, caused 
by toxaemia, or some poison not yet fully known, attended with 
much prostration and characterized by exudation or false mem- 
branes on tonsils and adjacent structures. When recovery follows 
it often leaves an altered voice, and may be followed by partial 
paralysis of the muscles of deglutition, weakness of the limbs, im- 
paired vision and secondary affections. This is a specific blood 
disease, more common to children than adults. No age or condi- 
tion is exempt, but it is most frequent and fatal in dump situations 
and badly drained districts and homes. 

Symptoms. — Premonitory, but not distinctive, are: First day, 
excitement; followed, second day, by general malaise, or feeling 
of depression, attended with muscular debility, slight sore throat 
and swelling of the lymphatic glands behind the jaw and cervical 
bones. 



110 SYMPTOMS. 

2. Then in the simple form, fever occurs, with headache, furred 
tongue, either constipation or slight diarrhoea, and difficulty of 
swallowing. On examination, a swollen and very red or purple 
appearance of the fauces, palate and tonsils. On the second or 
third day there will be seen a whitish or yellowish-white mem- 
branous deposit. This form of symptoms continue from five to 
nine days, and in favorable cases convalescence follows. 

3. The croupous form has about the same early symptoms, though 
often much more severe, and is prone to follow measles and scar- 
latina. This has caused the largest number of deaths, esj)ecially 
among children. This form proved very fatal recently in Dayton, 
Ohio. The symptoms are often violent in this form from the be- 
ginning; increase of soreness in the throat and difficult degluti- 
tion. Then there is found abundant yellow or brownish leathery 
exudation covering the tonsils and fauces, which are much swollen 
under the exudation. Often, quite early in the disease, the pseudo- 
membranous inflammation extends to the larynx, as the usual 
symptoms of croup present indicates by the barking cough and 
voice, difficult inspiration, whistling or sibilant when the obstruc- 
tion in breathing is the greatest. Now, a fatal termination may 
occur by asphyxia very early. This can only.be averted by the 
detachment or dissolution and expulsion of the accumulated mem- 
brane and the arrest of its renewal. 

4. The ulcerative variety is not common. When destruction 
of the palate and tonsils has attended it, with copious dark color- 
ed and pulpy exudation, and some extravasation of blood, it has 
been mistaken for, and described as gangrene ; whence the old 
name, "putrid sore throat." The occasional existence of true gan- 
grane cannot be altogether denied. 

5. Malignant Diphtheria begins with intense headache, often at- 
tended with vomiting, uncommon in milder forms, and hemorrhage 
from the mouth, nose, stomach or rectum. Dysphagia is soon 
great with enormous engorgement of cervical submaxillary and 
parotid glands. The palate, pharynx and tonsils are thickly cov- 
ered with a leathery deposit, at first yellowish, becoming ash- 
colored soon, then brown, and nearly black, giving an offensive 
odor. The tonsils often ulcerate and even slouch; the nostrils 
sometimes become swollen, lined with false membrane emitting an 



DIPHTHERIA. Ill 

acrid and fetid discharge. Early and extreme prostration ; often 
from the first day;Jthe pulse is very rapid; face lividly pale; 
niorbyi heat of the skin, followed by clammy coldness. Coma 
often precedes death, which may occur in three, four, or five, occa- 
sionally within one or two days. Sometimes death may occur 
quite suddenly from the severe impression of the poison upon the 
system before the Jocal affections are much developed. 

Special Symptoms and Complications. — Albuminuria is present 
in severe cases early in the case. Any raw or abraded surface, 
from a blister or other cause, will in the course of the disease be 
covered with false membrane. 

Pneumonia is an occasional and dangerous complication. 

Sequel.e. — Long-continued debility ; paralysis of soft palate ; 
various degrees of general paralysis, in which deglutition, articu- 
lation, vision and locomotion may be involved. Eecovery may 
very gradually succeed, or a fatal result may occur after a few 
weeks, or even after some months. 

Morbid Anatomy. — The deposit or pedicle formed upon the in- 
jected and tumefied mucous membrane of the fauces and throat 
constitute the anatomical peculiarity of diphtheria. Minutely 
examined, the false membranes vary from one-twentieth to one- 
eighth of an inch in thickness, and are fibro-laminated, or have 
layers of fibrinous network, including epithelial cells, and on its 
free surface exudation corpuscles or "pyroid globules" and granules, 
these forms appearing to be stages of degeneration. No progress 
of organization or development occurs in the mass — it is aplastic. 
In some cases only a granular superficial infiltration of mucous 
membrane is observed without even distinct fibrillation. 

Diagnosis.— From scarlatina diphtheria is distinguished by ab- 
sence of eruption, and the peculiar punctated or brick-dust like 
flush on the throat, and "strawberry tongue/' That scarlet fever 
predisposes to diphtheria, as a subsequent affection, is a well estab- 
lished and a very important fact. 

From membranous croup it differs in that croup is active, sthenic, 
with local inflammation, while diphtheria consists as much in gen- 
eral symptoms as local, and is epidemic, which croup is not, except 
as connected with diphtheria in the croupous form. The pseudo- 
membranous deposit commences in the trachea and larynx in 



112 DIPHTHERIA. 

croup, while in diphtheria it begins about the tonsils and pharynx. 
Alter laryngeal complication has occurred in diphtheria, that and 
croup symptoms run parallel. Excellent authors hold th£t all 
cases of membranous croup are really cases of diphtheria. For 
obvious reasons this cannot be conceded. 

From thrush and aphtha? diphtheria is known by the deposit 
being much larger and thicker, never vesicular; mostly duller in 
color, attended with severer constitutional symptoms. Thrush 
begins in the mouth ; it is more uncommon in adults than diph- 
theria ; is never epidemic. 

Prognosis. — The simple form is not dangerous ; the croupal 
form is decidedly so. The malignant is fatal in a large majority 
of cases. Insidiousness is a trait quite common to this malady, 
especially with children. For this reason some have applied the 
name of ''creeping croup" to it. In all except the simple form we 
should be careful of giving too much hope. 

Treatment. — To secure the best constitutional and local treat- 
ment the practitioner should accept the following propositions: 

1. In ordinary cases, the specific cause of diphtheria enters, the 
blood through the respiratory organs, and after an incubative 
period, varying from one day to a week, produces the character- 
istic symptoms of the malady. 

2. Experience does not confirm the opinion that internal anti- 
septic remedies can neutralize the poison, or protect the system. 
It is quite obvious that the amount of antiseptic medicine which 
would be required to preserve the blood and tissues from the action 
of the diphtheritic virus, would arrest molecular action, and con- 
sequently the vital functions, hastening a fatal result. 

3. Diphtheria is not self-limited, is unlike many other conta- 
gious diseases — like erysipelas, having no fixed duration. It may 
terminate in a few days, or persist many weeks. The virus acts 
with more intensity early in a case, its energy gradually abates. 
Early laringitis, etc., is very dangerous; coming on later it is less 
so in proportion. 

4. As yet, no specific antidote for diphtheritic poison is known, 
or in the sense in which quinia antidotes malarial maladies ; un- 
fortunately, no more than for typhoid fever, or scarlatina. It is 



DIPHTHERIA. 113 

hoped that such may yet be discovered. The nearest approach to 
an antidote in my experience, is fluid extract of pinus canadensis, 
internally and locally. 

5 The indications are to sustain the patient by nutrition, tonics, 
and judicious stimulation, and the employment of such general 
and local adjuvants as will fulfill any special indications which 
may arise. The treatment is quite parallel to that for scarlet fever, 
as already given for it. Local measures should be uniritating and 
such as will prevent the putrefactive changes and septic poisoning. 

I consider the local treatment, though essential, but secondary. 
The effort to remove patches of exudation by force, such as by ex- 
cision or actual cauterization, is simply pernicious, doing much 
harm without any compensating good. For an adult : 

R. Fluid extract pinus Canadensis, 3iij ; boiling water, 3vi. M. 
Use one tablespoonful as a gargle, thoroughly, every hour, and 
after each gargle swallow a teaspoonful. This, persistently em- 
ployed, usually arrests the diphtheritic process within three days ; 
often within twenty-four hours. 

R. Dilute muriatic acid, gtt xx ; water, Jijss. One teaspoonful 
every hour or two ; or 

R Dilute nitro-muriatic acid gtts xxv ; water, 3iv. One tea- 
spoonful every two hours, are good and cheap remedies, and 
seldom fail. 

These should be reduced in cases of children in proportion to 
the age. Dilute sulphuric acid, used in the same manner, acts 
more favorably in some cases. 

In the croupous form, the inhalation of the steam of lime-water, 
or the atomization of lime-water by the nephogene or other appro- 
priate apparatus, is often a good auxiliary. Flannels wrung out 
of hot water and vinegar, aa, and applied to the throat often af- 
fords marked relief. Hop fomentations are often better than vine- 
gar and water alone. Due attention should be paid to the cutan- 
eous surface in all cases. 

The diet is vastly important throughout the whole treatment. 
Milk, cr* am, good beef-tea or soup, or other very nourishing and 
digestible diet. If the patient is low, or suffering in the malignant 
form, egg-nogg, or milk-punch, as much and as often as tolerated 
until convalescence is attained ; then a variety of nourishing food 



114 DIPHTHERIA. 

may be alternated. Due ventilation and great care are required 
for the personal benefit of patients and to prevent the spread 
of the disease. 

Diphtheria so varies in its character of mildness, or malignancy, 
and complications, in different places and at various periods, that 
any definite and unexceptional treatment is quite impossible, as 
applicable to individual cases and epidemics. For this reason em- 
inent practitioners have seized upon diverse remedies and measures 
at various times, and extolled them as reliable in certain cases and 
epidemics which occurred under their observations, while others 
found these same remedies powerless, and others far more reliable. 
r Ihis gives a large margin for each physician to exercise his own 
care and discretion. We must study each case, approach each new 
advent of diphtheria, armed with a knowledge of all modes and 
measures preceding the time when we are called upon to act; then 
meet the responsibility as best we can, without preconceived or 
stereotyped notions and remedies. No two grave cases are ever 
precisely alike ; modifications in treatment will, of necessity, be 
again and again required. 

Diphtheria may have a fatal termination in various ways. Ob- 
servation has given the following immediate causes of death : 

1. Diphtheritic blood poisoning. 

2. Probably,^also, from septic blood poisoning produced by ab- 
sorption from the under surface of the decomposing pseudo-mem- 
brane. But it is difficult to distinguish the constitutional effects 
of sepsis from those" produced by the diphtheritic poison. Septic 
poisoning is obviously most apt to occur in those cases in which 
the pseudo-membrane is extensive and deeply imbedded and its 
decomposition attended by an offensive effluvium. Cervical cellu- 
litis and adenitis, which, when severe, cause very considerable 
swelling of the neck, appear to be often, if not usually, due to 
septic absorption from the faucial surface, the inflammation extend- 
ing from the absorbents to the glands and connective tissue. Con- 
siderable tumefaction of the neck, therefore, is seldom found in 
diphtheria or scarlet fever without manifest symptoms of toxaemia, 
and is to be regarded as a sign of its presence. 

3. Obstructive laryngitis. 

4. Uraemia. 



DIPHTHERIA. 115 

5. Sudden failure of the heart's action, either from the anaemia 
and general weakness from granulo fatty degeneration of the mus- 
cular fibres of the heart, which is liable to ensue in all infectious 
diseases of a malignant type, or from ante-mortem heart clots. 

6. Suddenly developed passive congestion and oedema of the 
lungs, probably due to feebleness of the heart's action or to paraly- 
sis of the respiratory muscles. Death has been known to take 
place apparently from this cause during the period of supposed 
convalescence, and when the visits of the physician had been dis- 
continued. 

Among the symptoms which render the prognosis unfavorable 
are : Repugnance to food, vomiting, pallor of countenance, with 
progressive weakness and emaciation from the blood poisoning; a 
large amount of albumen, with casts in the urine, showing uraemia, 
to which the vomiting is sometimes, not always, attributable; a 
free discharge from the nostrils, showing that a considerable por- 
tion of the Schneiderian membrane is involved ; hemorrhage from 
the nostrils or fauces, and obstructed respiration. One, at least, 
of these symptoms has been present in most of the fatal cases 
which have fallen under the author's observation. 

Diphtheritis and Tracheotomy.* — Dr. R. A. Kronlein gives many 
interesting practical facts connected with the treatment of diph- 
theria, based upon the results of five hundred and sixty-seven 
cases treated in Professor Langenbeck's wards between January 1, 
1870, and July, 1876. Of the five hundred and sixty-seven cases, 
three hundred and seventy-seven terminated fatally=66.4 per cent. 
A glance at the figures show that with every year the number 
of cases increased and the number of deaths diminished. The 
season of the year appeared to have some influence upon the ex- 
tent of the epidemic ; the smallest frequency was in the month 
of June, the greatest in October. Putting aside eight cases of 
adults between eighteen and forty-one years of age, we find that 
the frequency of the disease became gradually greater from one 
month upwards, reaching its greatest height at three years of age, 
continuing at this point up to four years and a half, and then de- 
creasing, until at the age of fifteen or sixteen years there was no 

* Langenbeck's Archiv. xxi. p. 253. Centralblatt fur die medicinischen 
Wissenschaften, November 17, 1877, No. 46. 

11* 



116 DIPHTHERIA. 

case. The younger the patient the greater the mortality. Trach- 
eotomy was performed five hundred and four times, stenosis of the 
larynx being always regarded as the sole guide for the operation, 
without regard to the age of the patient or the character of the 
disease. Of these five hundred and four operations^ three hun- 
dred and fifty-seven terminated fatally=70.8 per cent. Eighty- 
five of the operations were on infants under two years of age, 
of whom eleven recovered, and of these one wag but seven months 
old. Twenty eight of the cases had their origin in the hospital, 
and of these eighteen died. A detailed report is given of two 
hundred and forty-one cases, containing two hundred and ten 
tracheotomies. When the respiration does not become free imme- 
diately after the operation the prognosis is very unfavorable. In 
forty-six cases where this peculiarity was noticed forty-two died, 
91.3 per cent. The cause of this is to be found in the existence 
of a lobular pneumonia or of a deeply extending croup of the 
bronchial mucous membrane. When during the operation casts 
of the branches of the bronchial tubes are coughed up, and the 
respiration becomes apparently perfectly free, the prognosis is, 
notwithstanding, unfavorable. The operation was performed even 
when the children were brought in apparently moribund. There 
were twenty-two children operated upon in this condition, with a 
mortality of 90.9. Of the total number operated upon, one hun- 
dred and fifty-four died, one hundred with symptoms of asphyxia, 
the others under symptoms of gradual prostration or of sudden 
collapse. As a cause of the gradual prostration the frequent oc- 
currence of impediments to deglutition played a prominent part. 
These the author divides into two classes. In the great majority 
of cases this difficulty of swallowing takes place at the time of and 
is caused by the presence of the diphtheritic inflammation in the 
larynx and by the consequent rigidity through infiltration and exu- 
dation of the tissues which are involved in the act of swallowing. 
The cases that come on at a later period, after the complete heal- 
ing of the local inflammatory processes, are much rarer, and are 
then due to a secondary diphtheritic paralysis of the laryngeal and 
pharyngeal muscles. In fifty cases the tracheotomy wounds took 
on diphtheritic action, and of these twenty-eight terminated fatally. 
The method of operation was, without exception, in the latter 



MEASLES. 117 

years, the "tracheotomia superior" of Bose, which ofiered no in- 
surmountable difficulties even when there existed a goitre. Num- 
erous attempts to confine the diphtheritic process by means of local 
remedies did not give satisfactory results. 



MEASLES. 



Synonym. — Morbilli. Formerly, with all writers, and still with 
many, rubeola is a synonym for measles. Some English writers, 
however, designate by the name of rubeola only a hybrid or blend- 
ing of measles with scarlatina. 

Symptoms and Course, — After an incubation of from ten to fif- 
teen days from exposure to its contagion, measles begin with a 
slight or obscure stage of depression passing into fever. With 
this there are all the symptoms of a cold ; running at the nose, 
redness and watering of the eyes, and a cough. On the fourth day 
of the attack the rash begins on the face, and extends over the 
body and limbs. It is not so bright in color as the eruption of scar- 
let fever ; and is irregularly distributed in patches, more or less 
crescentic in shape. By about the seventh day the rash begins to 
fade, and about the same time or before the fever has begun to 
decline. Desquamation is much less extensive than after scar- 
latina. 

No such intensity of febrile movement, nor severity of any kind, 
as is common in the last-named disease, exists, except very rarely, 
in measles. Camp measles, during the late war in this country, 
often assumed a typhous character, with considerable mortality ; 
due to the conditions under which it occurred among the soldiers. 
Otherwise measles seldom threaten life. 

The sequeloz which are of the most consequence are, ophthalmia, 
diphtheria, chronic bronchitis, and phthisis. Very severe inflam- 



118 MUMPS. 

mation of the eyes sometimes follows measles ; but blindness from 
this cause is rare. Diphtheritic sore throat is not infrequent, and 
may be fatal in children. Chronic bronchitis is common, especially 
when care is not taken during convalescence to avoid exposure. 
Phthisis, under the same circumstances, is to be apprehended only 
where the constitution suffers under a predisposition to tubercular 
disease. 

Causatiom. — Measles is one of the most contagious of diseases, 
beyond all doubt. A second attack is exceptional, but not very 
rare.* 

Treatment. — Beginning with a moderately active saline cathar- 
tic, diaphoretics, expectorants, and demulcents are next in place. 
Syrup of ipecacuanha with neutral mixture Q drachm of the for- 
mer, for an adult, with each tablespoonful of the latter) every two, 
three, or four hours, would be an average treatment for the first 
week ; flaxseed lemonade being freely used as a drink. After 
that, the continuance or relief of the bronchial symptoms must de- 
termine whether some other expectorant (as lobelia squills or wild 
cherry) shall follow. Or, debility may require tonics during con- 
valescence. 

MUMPS. 

Synonyms. — Parotitis contagiosa; Cynanche parotidea. 

Symptoms and Course.— This is generally a mild affection, of a 
few days' duration. The parotid gland swells and becomes hot, 
painful, and tender to the touch. Some inconvenience in swallow- 
ing may result. There is little or no fever, but some general ma- 
laise ; and the attack is generally at an end within a week. One 
or both parotids may be affected. There seems to be reason to be- 
lieve that attacks may occur at considerable intervals, even of 
years, involving first one gland and afterwards the other. Suppur- 
ation is rare. This disease is undoubtedly contagious. 

Diagnosis. — As the parotid gland, as well as other glands about 
the neck, may inflame from cold, salivation, or scrofula, it becomes 

* Not long since, Dr. Salisbury, of Ohio, produced measles-like symp- 
toms in several persons by exposing them to the influence of fungi growing 
upon damp straw. The identity of the affection with measles is not, however, 
probable. Drs. Hammond and Woodward, at Washington, repeated the same 
experiment without result. 



HOOPING-COUGH. 119 

sometimes a question whether a swelling in that region be mumps 
or not. When the parotid alone is affected, it is impossible to de- 
cide, unless direct exposure to another case of mumps be known. 
The parotid is, however, not apt to inflame under other causation, 
even from salivation by mercury ; the submaxillary glands being 
much more liable to swell from that cause. The suddenness of the 
attack, and its brief duration, are generally also quite diagnostic 
of mumps, as compared with scrofulous or other inflammations 
of glands about the neck. 

Complications. — Metastasis of mumps, to the mamma or testicle, 
or, more rarely, even to the brain, may occur. In either of the 
first two cases a somewhat similar inflammation of the gland at- 
tacked takes place ; usually more protracted than that of the paro- 
tid. If the brain be the seat of the transfer of the morbid element 
or action, meningitis, or coma, may follow ; and even death is said 
thus to have resulted. Otherwise, mumps are free from danger 
to Jife. 

Treatment. — Care to avoid being chilled, lest metastasis or 
greater severity of the attack be produced, is important. No gen- 
eral treatment is apt to be necessary, nor does the patient usually 
need to remain in bed. Perhaps a mild laxative may be given on 
the first or second day. A poultice of flaxseed meal is a good local 
application for the gland. It may also be bathed night and morn- 
ing with soap or volatile liniment, or other discutient. 

HOOPING-COUGH. 

S ynon ym . — Pertussis . 

Symptoms and Course. — After an incubation of about six days, 
with symptoms much like those of acute bronchitis, including fever 
of variable degree, the attack commences ; soon showing its pecu- 
liar character. This is, a spasmodic and paroxysmal cough. For 
hours the patient may be apparently well ; and then, often with a 
premonitory sensation which leads the child to run to its mother 
or nurse, or, if at night, to sit up in bed, a fit of coughing begins, 
and lasts for several seconds or minutes. It consists of a rapid 
succession of short but violent expiratory efforts, with scarcely any 
intervals of inspiration ; at the close of which air is taken in by 
force through the contracted glottis, making a whooping sound. 



120 HOOPIKG-COUGH. 

whence the name of the disease. All who have it do not whoop ; 
but the paroxysmal character of the cough is pathognomonic. 

Expectoration is often copious, of thick mucus, sometimes even 
of lymph and pus. Vomiting frequently occurs during the spells 
of coughing. The child may become very much exhausted, even 
to a fatal end ; but unless from complication or previously feeble 
constitution, death does not very often occur. There may be many 
variations of severity in all the symptoms in the course of an 
attack. 

The duration of hooping-cough is seldom less than six weeks, 
although cases have ended within three weeks. Sometimes it 
lingers for three or four months. 

Complications. — Pneumonia, collapse of the lungs, and (as a 
sequelae) phthisis, are the most liable to occur. Deafness from 
rupture of the membrana tympani during the violent coughing, 
has been known. Sometimes the eyes become blood-shot from the 
same cause. Convulsions occasionally increase greatly the serious- 
ness of the disorder. 

Causation and Pathology.— There is no question of the con- 
tagiousness of hooping-cough. Generally it occurs but once in 
the same person ; but second attacks are not very rare. Like 
scarlet fever, measles, etc., it is most often met with in children ; 
but this is merely from their susceptibility under exposure ; as 
adults also have it. 

Belonging among the zymotic diseases caused by a specific mor- 
bid poison, the spasmodic nature of the cough points to the nerv- 
ous system as in main part the seat of its action. Yet the expec- 
toration, as well as early (and occasional, afterwards) febrile symp- 
toms, show that bronchial inflammation exists to some extent, sec- 
ondarily at least. 

Treatment. — Mild cases need only care to avoid exposure to 
damp and cold. After the first few days, if there be no fever nor 
soreness of the chest, the patient need not be kept in the house 
during good weather. Indeed, he will cough least when most out 
of doors. When the cough, at first, is tight and painful, with little 
expectoration, syrup of ipecac, lobelia, or squills, may be given. 
As soon as the spasmodic character of the cough declares itself, 
with some violence, the "milk" or the tincture of assafoetida may 



INFLUENZA. 121 

be given : with or without other expectorants according to the 
case. Severe cases may be quieted by belladonna, hyoscyamus, 
musk, or hydrate of chloral. Hydrocyanic acid, or bromide of am- 
monium (from two to twelve grains at once for a child), nitric acid, 
alum, clover tea. chestnut-leaf tea, and benzoic acid are among 
the other remedies often employed to allay the violence of the 
paroxysms. 

In protracted cases counter-irritation to the chest and back of the 
neck may be required. Tonics are also not unfrequently called for 
toward the end of the attack in a feeble child ; especially quinine, 
or tincture of bark (Huxham's), iron, or cod-liver oil. There is 
very seldom need to restrict the diet in this disease, unless during 
the first week. 

INFLUENZA. 

Synonym. — Epidemic Catarrh. 

History.- -Although, among many persons exposed to the same 
weather, catarrhal affections are of course common at certain times, 
there is evidence that, apart from the conditions of humidity and 
temperature of the air, epidemic catarrh sometimes occurs as a zym- 
otic disease. The local prevalence of influenza may exist at very 
irregular periods, and sometimes so mildly as not to be distinguish- 
ed from common sporadic catarrh. 

Symptoms and Course. — The ordinary symptoms of a "bad 
cold" are those of influenza; but the illness is somewhat more 
severe, and prostration is generally greater. Of this there are all 
grades, however. Bronchitis, sometimes capillary, and pneumonia, 
are not rare complications. Old people are especially apt to be 
carried off by influenza. Its mortality is very small among persons 
in early or middle life. The duration of an attack is commonly 
from three to ten days. 

Causation. — The hypothesis has been entertained, in conse- 
quence of the irritating effect of ozone upon the air-passages, that 
an excess of it in the atmosphere may be the cause of influenza. 
But no facts raise this supposition beyond conjecture. 

Treatment.' — Mild cases require housing and little more. A 
warm mustard foot-bath at night, followed by a large draught of 
hot lemonade if there be chilliness, or the same taken cold if fever 
exist — and a dose of solution of citrate of magnesium or Rochelle 



122 DENGUE. 

salt or senna tea in the morning, will generally suffice. Sweet 
spirit of nitre may be added to the night draught if the skin be 
dry and the urine scanty. 

Great prostration, especially in old people, may call for support, 
by quinine and stimulants. Hot whisky punch is, for such a case, 
not out of place. The abortion of an attack of influenza is some- 
times practicable within the first two days, by giving quinine, in 
four-grain doses, thrice daily. Bronchitis or pneumonia, as com- 
plications, will require treatment as in other cases. 

DENGUE. 

Synonym. — Break-bone Fever. 

History. — Frequently in the Southern United States, occasion- 
ally in the Northern (at least Dr. Rush seems to have described it 
at Philadelphia in 1780), and in the East and West Indies, this 
disorder has occurred. English writers regard it as a variety 
of scarlet fever, naming it Scarlatina rheumatica. 

Symptoms and Course. — Usually after a chill, fever comes on, 
moderate in degree, but attended by considerable debility, and 
severe pains in the head, back, and joints; the latter being some- 
what swollen. In about two days or less, the fever subsides, and 
the pains lessen, though they do not disappear. Toward the end 
of a week from the commencement of the attack, a rash breaks 
out, resembling that of scarlatina, or duller and more in patches. 
The fever returns, often, about the fourth or fifth day, and lessens 
or ceases after the eruption has come out. All the symptoms grad- 
ually subside, leaving the patient well but very weak, by the be- 
ginning or middle of the second week of the attack. This disease, 
without complication, is never fatal ; nor does it leave any sequelae 
except debility. 

Its causation is not known, beyond what is comprised under 
the term " epidemic influence " It is noticeable that it affects 
more persons at one place and time than almost any other epi- 
demic ; nearly all the population may have it in one season; all 
ages and both sexes being alike attacked. 

In treatment, dengue requires merely good nursing — regulat- 
ing the bowels, and relieving or mitigating the pains with Dover's 
powder or other opiates, especially at night, or by the local appli- 
cation of laudanum, etc. 



MALARIAL FEVER — INTERMITTENT FEVER. 123 

MALARIAL FEVER. 

Varieties. — Intermittent, Remittent, and Pernicious Fever. These 
may all be properly regarded as grades or modifications of the 
same type of disease ; agreeing in the nature of their cause, the 
periodicity of their s3 T mptoms, and their mutual convertibility. 
Each will, however, require a separate description. 

INTERMITTENT FEVER. 

Synonyms. — Ague; Chills and Fever. 

Varieties. — Quotidian, when the paroxysm occurs every day; 
tertian, when it is every other day ; quartan } on the first and fourth 
days ; also, quintan, sextan, septan, and octan. The quotidian and 
tertian are common ; the octan, or weekly return of the attack, is 
not unfrequently met with ; the others are very rare. The time 
between two paroxysms is called the intermission (apyrexia) ; the 
period from the beginning of one chill to the beginning of the 
next is the interval. Paroxysms are sometimes double; as, double 
quotidian, with two paroxysms on one day ; double tertian, with 
a paroxysm every day, but those of every other day corresponding 
in time or character, etc. These are rare. 

Symptoms and Stages. — No disease has ordinarily so regular a 
succession of definite stages as intermittent fever, viz : the cold, 
the hot, and the sweating stage. 

Cold Stage, or Chill. — Beginning with languor and yawning, a sen- 
sation of coldness comes on, often creeping and shivering, with 
chattering of the teeth and rigors or tremulous movements. The 
skin has a sunken appearance, and the lips and finger-ends may be 
blue. The sense of coldness does not prove a low temperature 
of the body ; which the thermometer .sometimes shows to be even 
hotter than natural. Thirst exists, with loss of appetite ; occasion- 
ally, vomiting. Headache, depression of spirits, and drowsiness 
are common. Perspiration is absent, but the urine is abundant 
and nearly colorless, with a low specific gravity. The duration 
of a chill varies from ten minutes to two or three hours ; averaging 
not more than three-quarters of an hour. 

Hot Stage; Pyrexia. — Gradually warmth is felt to return ; the 
shivering ceases ; a flush succeeds the pallor or lividness of the 
face. A real increase of the heat of the surface is found by the 
thermometer; reaching 105° to 110°; seldom more than 106°. 



124 INTERMITTENT FEVER. 

The mouth becomes dry, the tongue furred ; vomiting is common, 
with total anorexia. Headache is apt to be violent; but delirium 
is rather exceptional. The pulse is accelerated, and generally 
strong and full. The bowels are constipated ; the skin dry, the 
urine scanty and high-colored. The hot stage may last from an 
hour or two to sixteen or eighteen hours. 

Sweating Stage.-This also comes on gradually; the face first be- 
coming moist ; then the trunk and limbs. This is attended by in- 
creased comfort ; the headache lessens, the stomach if disturbed 
becomes quiet, the patient often goes to sleep and sweats profusely 
all over. After this, the fever has gone ; the pulse is slow and 
soft, the skin cool. The urine is now passed freely, and deposits a 
brickdust-like (lateritious) sediment. There is no definite length 
of time to be assigned to the sweating stage. 

Of the three stages, now and then one or two may be wanting. 
There is then only a chill, or a fever, or a sweat, occurring daily, 
or every other day, at the same hour. Or, a paroxysm of pain 
may occur in one part of the body, with the same regularity. One 
form of this is called "brow ague." Dumb ague is a popular name 
for an attack in which the chill is absent or obscure, the other 
symptoms recurring periodically. There seems to be no doubt that 
a single limb, or even a single finger, may go through all the three 
stages — cold, hot, and sweating ; the rest of the body being unaf- 
fected. Intermittent neuralgia is very common in malarial districts, 
especially after chills and fever. In the same regions, all com- 
plaints are apt to take on periodicity ; so we may have intermit- 
tent dysentery, pneumonia, etc. 

The intermission is often a time of apparent health, except some 
debility, and perhaps headache with want of appetite and of good 
digestion. 

The great number of paroxysms of intermittent occur in the 
daytime. An attack which began as a tertian, may become a quo- 
tidian ; or the converse may happen. Intermittent sometimes 
passes into remittent fever ; though much less often than remittent 
becomes intermittent. 

Sequels. — Protracted intermittents are often accompanied or 
followed by anaemia, of a marked character, and by enlargement 



INTERMITTENT FEVER. 1^0 

of the spleen and liver ; especially of the former. Dropsy is a quite 
frequent result of these visceral affections or of the anaemia. 

Morbid Anatomy. — Melanozmia, or pigmentary degeneration 
of the blood-corpuscles, with deposit of pigment granules in the 
liver, spleen, kidneys, brain, etc., is almost a characteristic of ma- 
larial disease. Enlargement and softening of the spleen, and en 
gorgement of the liver, with a bronzed appearance of it, are the 
only other peculiar changes of structure. 

Diagnosis. — One chill can hardly ever be certainly pronounced 
to be malarial, because very many acute disorders begin with a 
cold stage. Two, with a distinct apyrexia, cannot often be con- 
founded with anything else, except hectic fever. In the latter, 
there is usually a known cause for the symptomatic febrile symp- 
toms ; the patient is weak and emaciated, the paroxysm is irregular 
in time and duration, there is a bright roseate flush upon the cheek, 
and headache is usually absent. 

Prognosis. — Left to itself, intermittent will sometimes get well 
as early as the seventh, eighth, or ninth paroxysm ; more often it 
will last ten weeks ; sometimes as many or more months. 

Under treatment, it is almost always possible to break the chills 
by cinchonization ; but they frequently return ; especially at the 
end of one, two, or three weeks. It is a good sign for the paroxysm 
to occur later and later in the day, and to become shorter and 
shorter. Tertian ague is generally the most readily cured ; quar- 
tan the most intractable, though comparatively uncommon. Death, 
in modern times, since the discovery of the properties of Peruvian 
bark, almost never happens from the ordinary type of intermit- 
tent ; the pernicious form is very dangerous. 

Causation. — Upon the origin of malarial fevers, the following 
facts seem to be established : 

1. They are reasonably designated as autumnal fevers, because 
very much the largest number of cases occur in the fall of the 
year. Spring has the next greatest number of cases. 

2. They are always strictly localized in prevalence. 

3. They never prevail in the thickly built portions of cities. 

4. An average summer heat of at least 60° for two months is 
necessary to their development. Their violence and mortality are 
greatest, however, in tropical and sub-tropical climates. 



126 INTERMITTENT FEVER. 

5. They prevail least where the surface of the earth is rocky ; 
and most near marshes, shallow lakes and slow streams. The 
vicinity of the sea is free from them, unless marshes lie near it. 

6. The draining of dams or ponds, and the first culture of new 
soil, often originate them. 

7. Their local prevalence in the autumn is generally checked by 
a decided frost. 

Upon these facts, it was a legitimate hypothesis (urged especially 
by the late Professor J. K. Mitchell of Philadelphia) that the ma- 
terial cause of malarial fevers is a minute vegetative organism, 
whose substance or emanations enter the body. Professor Hannon 
of Brussels relates that he learned in 1843 from Professor C. Mor- 
son, and verified the statement in his own person, that the exhala- 
tions of certain fresh- water algae would produce ague. 

Dr. Salisbury, of Ohio, has recorded in the January number 
of the American Journal of Medical Sciences, for 1866, some observa- 
tions and experiments, tending to show that minute cryptogamic 
plants of the family of Palmellae, abounding over the surface of 
marshes, can generate intermittent fever, when transported to 
localities otherwise free from it. Such results require of course 
repeated investigation to make them actually matters of demon- 
stration. 

Treatment. — One remedy in this disease overshadows all others 
— cinchonism. By this we mean, the production of the constitu- 
tional impression of the cinchona bark, or of one of its essential 
constituents. At any stage it appears to be safe unless it be the 
very height of the pyrexia. Nor, as a rule, is any special prepa- 
ration necessary. 

It is well, always, during the chill, to promote speedy reaction 
by external warmth, and perhaps by hot drinks, of a not too stim- 
ulating character. The bowels ought to be opened well, and the 
stage of fever may be palliated by the free drinking of cold water, 
made more diaphoretic by the addition, if necessary, of neutral 
mixture or effervescing draught. Then, as soon as sweating fairly 
begins, the quinia, or cinchonia, or cinchonidia, or bark in sub- 
stance may be prescribed. 

The sulphate of quinine has the most universal reliance. Some 
give it in doses of several grains, each twice daily. Others prefer 



INTERMITTENT FEVER. 127 

to give one grain every hour. The amount required in the inter- 
mission of ordinary intermittent is about fifteen to twenty-four 
grains. Less may often cure, but can hardly be depended on. 
The quinine may be given in pill or in solution. Direct that, in 
tertian ague, the patient begin early on the day of the intermis- 
sion, and take one grain every hour till he has taken twelve grains. 
The next day let him begin at the same rate, and, if no chill occur, 
take ten grains. The third day nine ; and so diminishing daily 
until six grains are reached. Let this be continued till a week 
from the last chill, when a greater tendency to return will exist ; 
on that day let ten grains again be given. After that time, if no 
paroxysm has occurred, he is, for the time at least, well. 

Sulphate of cinchonia, in doses one-half greater (gr. jss instead 
of one grain) has succeeded in a considerable number of cases. It 
generally produces much less ringing in the ears than quinine, and 
can be taken by some whose heads do not bear that medicine. 
Bark in substance, especially Calisaya bark (an ounce in the in- 
termission), is of course perfectly reliable ; but it is disagreeable 
and oppressive to the stomach, and should only be used when its 
derivatives cannot be obtained. Cinchonidia is equal to quinine 
and free from objection. 

Other remedies in considerable number have obtained more or 
less reputation in the treatment of ague. Opium, given in full 
dose (say sixty drops of laudanum) shortly before the time of an 
expected chill, has been found generally to abort it. Arsenic (ten 
drops of Fowler's solution thrice daily) is considered to approach 
very nearly in certainty to the preparations from cinchona. Sul- 
phate of copper is asserted by some (in \ grain doses) to be anti- 
periodic ; and so is nitric acid (ten drops thrice daily, diluted) ; 
and common salt (a drachm at a dose, half an ounce during an 
intermission). Dogwood bark : pepper, and its extractive, piperin ; 
willow bark, and salicin obtained from it, have also some reputa- 
tion of the same kind. Chloroform, taken by the mouth, has been 
used with success by Dr. Merrill. He gives f3,j at once, at the 
beginning of the chill. It may be diluted with mucilage. A 
strong impression of almost any kind upon the system during the 
apyrexia, may arrest or prevent the paroxysm. So may act the 
drawing of a blister upon the spine ; or a cold shower-bath. 



128 REMITTENT FEVER. 

But the breaking or interruption of chills, though generally cura- 
tive of a first attack, is not nearly always so in a second or third. 

Chronic intermittent may maintain a constant tendency to re- 
lapse, in spite of cinchonism. In such a case, anaemia and the 
malarial cachexia are usually present. Here the great remedy is 
iron. Give it in some form ; with a grain of quinine in each dose, 
continuing it for several weeks, three times a day. 

REMITTENT FEVER. 

Synonym. — Bilious Fever. 

Varieties. — Simple and malignant. The latter, however, will 
be described under Pernicious Fever. 

Symptoms and Course. — Although the promonitory stage is 
usually short, and not unfrequently wanting, its general occurrence 
is well established. Its symptoms are those of general malaise, 
with some headache, slight nausea, and furred tongue. These in- 
crease, until a chill, not violent, but lasting sometimes half an 
hour or an hour, fairly begins the attack. Or, an ill-defined cold 
stage, with a feeling of chilliness, languor, and debility, and per- 
haps cerebral oppression and gastric disorder, may occur. 

After this, the febrile condition is developed. The skin becomes 
hot, dry, and harsh ; the pulse rises in force and frequency, although 
less hard and tense than in some diseases, and not exceeding gene- 
rally, during the first exacerbation, 110 or 115 beats in the minute. 
The face is flushed ; headache is throbbing and severe ; the facul- 
ties being unfitted for any mental exercise. Violent pain is almost 
always felt in the back, and very often also in the limbs. Epigas- 
tric uneasiness is nearly universal ; nausea and vomiting extremely 
common. Bilious matter is in many instances ejected from the 
stomach. The bowels are costive ; when opened, however, the 
stools are colored with bile. The urinary secretion is scanty. 
Thirst is always great ; cold drinks being much preferred. Respi- 
ration is hurried, although free. 

After a continuance of from eight to twenty hours, these symp- 
toms abate more or less, even without treatment. The feelings 
of the patient are more comfortable ; he sleeps ; and wakes with a 
skin less hot, and moist, perhaps even with considerable perspira- 
tion. Headache, however, and some pain in the back remain ; 
and the pulse does not subside to the natural standard. In some 



REMITTENT FEVER. 129 

instances it is little altered. The stomach, however, is less dis- 
turbed, and thirst is somewhat less intense. 

There is reason to believe that a few cases of genuine malarial 
remittent may, by prompt treatment during the hot stage, be 
quelled, so as not to advance beyond the first exacerbation and 
remission. We ascribe their facility in yielding, chiefly, to a less 
degree of intensity in the morbific cause. 

Mostly, in from six to twenty-four hours, the patient's discom- 
fort again increases ; the skin becoming even hotter than before, 
and quite dry ; the pulse rises to 120 in the minute ; thirst is 
great, although sometimes less than in the first paroxysm ; the 
headache returns, and with it usually severe pain in the back. 
The tongue is now thickly furred, often with a yellowish hue. 
Xausea and disgust for food are again felt, and in a large number 
of cases vomiting returns ; the stomach rejecting everything, even 
cold water. The stools, when obtained, are sometimes, slate-color- 
ed ; but more often decidedly colored with bile. Diarrhoea, is un- 
common, and is most apt to accompany a later stage. Delirium is 
common only in violent cases ; restlessness is almost universal. 
Yellowness of the skin appears in a majority, in various degrees. 

The advance of the disease, after the second paroxysm, is ex- 
ceedingly various. The periodical character, however, is main- 
tained throughout. The remissions may occur at any hour — in 
moderate cases being as often in the afternoon as in the morning ; 
in the protracted more commonly in the morning, the fever lasting 
through the night. Quite frequently a double tertian type is ob- 
served ; the exacerbation occurring one day in the morning, and 
the next in the afternoon ; and sometimes with different degrees 
of violence. 

Duration. — Favorable cases often terminate in six or seven days 
in an intermission, which in some becomes a cure even without 
any anti-periodic treatment. The more violent, especially if ill- 
managed or in an abnormal constitution, may be protracted for 
three, four, or occasionally five or six weeks. We should distin- 
guish, however, between the true periodical disease and its sequela?.. 
The average duration of a case of remittent fever may be stated 
as about fourteen days. 

Complications. — These are usually dependent on local inflamma- 
tions. The brain is perhaps the organ most frequently affected. 



130 REMITTENT FEVER. 

with cerebritis or meningitis. In late autumn, or other oool weath- 
er, pnevmon iais not uncommon. Gastritis and enteritis— diarrhoea 
and dysentery of an obstinate character sometimes occur. When 
any of these affections exist, they partake to some extent of the 
periodical character of the fever ; and are often lessened or remov- 
ed by the treatment adapted to it, In other cases, however, they 
remain in a subacute or chronic form ; and, when death occurs, in 
a majority of instances the immediate cause is a violent phlegmasia 
of some organ. Hepatitis and splenitis are more common in the 
chronic form than in the acute — and as sequelae rather than com- 
plications of the attack. 

The Typhoid State. — At any time after the fourth or fifth day, 
but particularly near the end of the second week, a patient suffer- 
ing with remittent fever may pass into the condition designated by 
the above term. Its features vary somewhat ; but it is usually 
marked as follows : Pulse 120 to 140, and rather deficient in 
strength ; skin harsh, varying, however, with the slight remissions 
in dryness and temperature ; face dark or flushed ; head hot ; de- 
lirium, active more frequentty than comatose ; bowels occasionally 
affected by diarrhoea, but as often costive ; tongue heavily coated 
with sordes, brown or black, and with cracks or fissures across it. 
Muscular debility is usually great. Hemorrhages from the bowels, 
lungs, or stomach, occasionally increase the danger. 

Where death occurs within the first three weeks, it is almost 
always the result of some inflammatory complication. Remittent 
fever rarely proceeds to a fatal termination by mere exhaustion 
of the powers of nature. In feeble or aged persons, however, this 
may occur. 

Sequels; — A slow and imperfect convalescence not unfrequent- 
ly follows a violent attack.; attended with sallowness of the skin, 
feeble digestion, muscular and nervous debility. The only organic 
alterations at all constant are enlargements of the liver and spleen. 

Morbid Anatomy. — The most striking observation upon this 
was that made at the Pennsylvania Hospital by Dr. T. Stewardson, 
in 1841, of the unusual color of the liver; bronzed without and 
olive-green within. Subsequent confirmation of this has been 
afforded ; although Dr. Drake, of Cincinnati, failed to find it in 
his autopsies. The spleen is almost always enlarged, congested, 



REMITTENT FEVER. 131 

and softened. Inflammation of different organs (mating fatal 
complications), especially the brain, lungs, or bowels, may ex- 
hibit the usual results. Such lesions, however, are scmetimcs ab- 
sent in the most malignant cases. Pigment-liver has been refer- 
red to already. 

Causation. — This has been considered under the head of inter- 
mittent fever. 

Diagnosis. — Yellow fever has by some physicians been regarded 
as identical with remittent, differing mainly in the grade of its 
violence. The correct view is, that they are specifically distinct 
diseases. To prove this, we might be satisfied with the simple 
fact of the different localization of the two fevers. Remittent is 
always a country fever ; yellow fever almost invariably a disease 
of towns and the vicinity of the sea. The latter is restricted much 
more narrowly, also, in its actual geographical limits. 

But there are symptomatic differences also ; which may be best 
pointed out after giving a description of yellow fever. Among the 
important points, one is, that an attack of the latter disease com- 
monly gives immunity from it for life ; but this is not at all the 
case with remittent fever. 

When the typhoid state supervenes, there may exist very con- 
siderable similarity to the true typhoid fever. It is asserted that 
a coexistence of the two diseases occurs. Some, upon the same 
facts, ground the opinion that they are not specifically different ; 
but that typhoid fever is merely a protracted remittent of low form. 
This is, however, contradicted clearly by at least two facts : 1, the 
comparative rarity of typhoid fever in regions where remittent 
most abounds; and 2, the frequent prevalence of the typhoid where 
remittent fever is almost unknown ; as in some of the Eastern 
States. 

The mode of onset in the two, moreover, is usually quite differ- 
ent; in typhoid, insidious and almost imperceptible at first; in 
bilious fever, after a day or two of malaise, a chill abruptly ushers 
in the attack. Vomiting is extrmely common in the one— quite 
rare in the other; the converse is true of diarrhoea — and still more 
particularly of tympanites and abdominal tenderness. The deaf- 
ness, and sleeping stupor — and livid countenance of typhoid fever, 

are almost entirely peculiar. Epistaxis, bronchitis, and the rose- 

12* 



132 REMITTENT EEVER. 

colored eruption, so nearly constant in the latter, are rare in the 
typhoid remittent ; the last mentioned is perhaps never observed. 
The yellowness of the skin, also, and the distinct remissions, mark 
well the remittent attack. In dissection, we find more gastric and 
hepatic change after bilious fever, and more enteric and splenic alter- 
ation in the typhoid. 

Prognosis. — Recovery may be anticipated in a majority of in- 
stances. Before the use of cinchona, remittent was often quite 
fatal. 

Favorable signs are, the earlier occurrence and prolongation 
of the remission, and its becoming more and more complete; moist- 
ening and clearing of the tongue ; copious perspiration ; turbid- 
ness of the urine, from increase in the amount of its solids ; tar- 
like and offensive stools ; and the appearance of vesicles about 
the lips. 

Unfavorable, of course, are, the shortening and postponement 
of the remission, and its indistinctness ; dryness, and blackness 
of the tongue ; retention, or, still worse, suppression of urine ; ex- 
treme frequency, with weakness, of the pulse ; hiccough ; and other 
important evidences of the victory of disease over the vital func- 
tions — not, however, peculiar to the fatal termination of this 
disease. The supervention of the usual symptoms of inflammation 
of the brain is always very alarming; gastritis may occasionally 
threaten to wear out the patient's strength ; and pneumonia is at- 
tended with more danger when occurring as a complication of fever, 
than when an original disease. 

Treatment. — In a person of robust constitution, if the headache 
be very severe, skin hot, and pulse full as well as rapid, it is com- 
mon to administer a saline cathartic. Epsom salts will be the best 
when the stomach is but little disturbed — the Seidlitz powders in 
repeated doses under contrary circumstances may answer. If ob- 
stinate vomiting prevail, as will frequently happen, no purgative 
will suit so admirably as the effervescing solution of the citrate 
of magnesium. Hydrotherapeutics are indicated to cool the body. 
When the fever is active and temperature high, aconite, or vera- 
trum, should be given, and the skin frequently sponged with warm, 
tepid, or cold water. 

As a refrigerant diaphoretic, the citrate of potassium solution, 
with or without effervescence, may be constantly given. 



REMITTENT FEVEK. 133 

Special treatment may often be called for by the great intracta- 
bility and distress of stomach. Lime-water or magnesia in small 
doses with ammonia and an aromatic will frequently relieve. 

Sinapisms and pediluvia are of course useful adjuvants. Ice will 
answer better to quench thirst than water, where gastric irritability 
is great ; otherwise free dilution by drink is an advantage. 

As soon as the violence of systemic excitement has been moderated — 
without waiting for its entire subjugation — if the pulse has begun 
to' subside — lowering, for instance, from 110 or 120 to 90 or 100, and 
the headache is less intense — the bowels freely moved — we may begin 
with quinine, or cinchonidia ; but it is unnecessary here to give 
large doses generally. Unless where some malignancy is suspect- 
ed, or the remission is very complete, a single grain every two hours 
will be sufficient at first. Under this, after reducing measures, we 
may find the pulse continue to subside — the skin to moisten, and 
all the symptoms to improve. At all events, in the next remission, 
the dose should be increased to a grain every hour — not, as a general 
rule, however, awaking the patient from sleep. Two grains every 
hour for eighteen hours, is the freest administration ever necessary 
in a case even threatening malignancy. This term, it need hardly 
be said, is used to express the existence of a state of prostration, 
attended with signs of visceral congestion, increasing dangerously 
with each paroxysm ; reaction being deficient, as we believe, from 
an unusual intensity of the morbid cause — or defect of constitu- 
tion. Such cases do require a large amount of the special remedy; 
and such cases are no doubt much more frequent in warmer South- 
ern States than here. We have no difficulty in believing in the 
toleration, or even the propriety, of considerably larger doses than 
are here given ; but there is a limit even there, to go beyond which 
is excess. Parhaps we should allow somewhat in the estimate in 
some remote places, for the immense adulteration of valuable drugs 
which prevails. Many practitioners in the Southern States insist, 
that no preparation whatever for the use of quinine is necessary; 
and that it may be given with safety and advantage throughout 
the hot stage of the fever. This is of doubtful propriety. 

After two or three days of constant "quininization" the amount, 
usually, may be diminished to six or eight grains, distributed 
through the period of convalescence. 



134 PERNICIOUS FEVER. 

The treatment of inflammatory or other complications must of 
course superadd modifications appropriate to each. We have 
named, in the above sketch, all the main elements of the plan which 
is found successful in such cases as ordinarily occur. 

The existence of local inflammations, in a genuine malarial case, 
does not contraindicate the use of quinine. Being lit up by the 
fever-poison — and aggravated by its febrile state, the treatment 
which annuls or removes these will often lower or check the pleg- 
masia. But this maxim should be applied with caution and some 
exceptions, in cases particularly of cerebral inflammation, or great 
pulmonic oppression, which require special means. 

In slow convalescence, w T ith sallowness and deranged digestion, 
the daily administration for a few days of minute doses of leptan- 
drin or podophillin generally proves useful. And, to improve san- 
guification, as well as to lessen the danger of relapse in some form, 
the protocarbonate of iron, in pill with a portion of sulphate of qui- 
nine, will make a very valuable termination of the treatment. 

PERNICIOUS FEVER. 

Synonyms. — Congestive Fever; Malignant Intermittent; Malignant 
Remittent. 

Symptoms and Course. — Unlike ordinary intermittent, a par- 
oxysm of the pernicious form may commence either in the day or 
night. At first, however, in many cases, it begins like the common 
type of chills and fever, or remittent fever; after one, two, or 
three days becoming more alarming. 

Then, the skin grows lividly pale, shrunken, and sometimes 
clammy with cold sweat ; the countenance anxious ; the tongue 
either pale, furred, or natural ; in the worst cases it is cold. Thirst 
is intense, with a sense of internal heat. The stomach is exces- 
sively irritable, and vomiting is common, of mucus, or a muco- 
serous or even bloody fluid. The bowels are in most cases loose, 
the dejections resembling bloody water. The pulse is usually small, 
weak, and rapid or irregular ; in a few instances corded. The 
respiration is interrupted and sighing, with a sense of oppression. 

Restlessness is common ; but the mental faculties in many cases 
are clear. There are, however, many instances in which the weight 
of the attack falls on the brain. Then, the early symptoms are 
drowsiness and hesitation of speech. Stupor marks the depth 



Pernicious fever, 135 

of the paroxysm. The breathing maybe stertorous; or tetanic 
spasms may occur. The pulse, in the former case, may be slower 
than in the other form described; but it is still. weak, and, even 
if the head be somewhat warm, the vessels of the neck and temples 
are not apt to be swollen, and the skin of the body is cold. 

Partial, or, it may be, complete reaction in most instances fol- 
lows after three or four hours of the above symptoms ; though 
death may, instead, take place in the collapse. Again, the fever 
may intermit, or remit ; and, at the same or an earlier hour the 
next day, another paroxysm occurs. This is more dangerous than 
the first. If a third be allowed to take place, it is generally fataL 

Morbid Anatomy. — Congestion, of the brain, liver, spleen, and 
alimentary mucous membranes, is so prominent an autopsic phe- 
nomenon as, with the symptomatic appearances of the same, to 
have seemed to justify the older and more common name of the 
disease. We have good reason to believe, however, that the tox- 
emic impression of malaria, and its effects upon the nerve-centres 
(either of organic or of animal life), are primary, and the conges- 
tion secondary. 

Diagnosis. — The intensity of the symptoms, and the general pros- 
tration, or coma, will distinguish this from ordinary intermittent 
or remittent. The aspect of a severe case is not unlike that of an 
attack of epidemic cholera ; but the discharges are different ; and 
the locality and season, unless in the presence of that epidemic, 
will point directly to malarial causation. 

Prognosis.-^- Without appropriate treatment, a large majority 
of cases would be fatal. There are few diseases displaying a greater 
tendency to death. Under cinchonism, and other proper manage- 
ment, not more than one in ten probably die. 

Treatment. — As above implied, quinine is our great reliance in 
this disease. Larger doses are required, also, than in ordinary in- 
termittent. While opinions differ, the best evidence shows that 
from thirty to sixty grains of quinine in twenty-four hours will do 
all that the remedy can do ; more will be wasteful and dangerous. 

But, in most cases, other means must be employed, sometimes 
before quinine can be kept upon the stomach, to promote reaction. 
External stimulation is foremost among these means. Direct heat 
may be applied, by hot-water bottles or tins, hot bricks, or bags 






136 PERNICIOUS FEVE&. 

of hot salt laid along the spine, or by the hot bath. Thirst should 
at the same time be quenched by cold water, or, if the sense of heat 
is great, and vomiting occur, with ice. Mustard plasters may be 
placed upon the spine, epigastrium, or limbs ; or the extremities 
may be rubbed with brandy and red pepper. 

The opposite of this plan is preferred by some, upon asserted 
favorable experience, viz : the pouring or dashing of cold water 
quickly upon the naked body. Extensive dry cupping along the 
spine is recommended by others. 

Internal stimulation, also, is demanded under the same circum- 
stances. Most used have been camphor, opium, ether, oil of tur- 
pentine, ammonia, and capsicum, besides wine and brandy or 
whisky. The best testimony is in favor of camphor and opium, 
with quinine, in moderate doses every half hour during the chill, 
when no comatose symptoms are present. If these exist, oil of 
turpentine, by the mouth or rectum, has its decided advocates. 

Alcoholic stimulants seem to be indicated in the collapse. A 
tablespoonful of brandy or whisky every half hour or hour until 
reaction occurs would be a suitable average. 

After reaction has been established, even imperfectly, and an 
intermission or remission exists, the "sheet anchor" is quinine. 
Then if the stomach bear it, five to ten grains may be given every 
two or three hours, until cinchonism is fully established. When 
the quinine is rejected by the stomach, hypodermic injection may 
be resorted to. Ten grains or more may be introduced at once, 
in solution in water, with sulphuric acid enough to dissolve it 
perfectly. 

In the cerebral cases, podophillin is particularly appropriate. A 
blister to the nucha may be recommended in the same cases. Pur- 
gatives are also apt to be required ; and, if the heat of the head 
be great, iced water may be kept applied over it, while hot bottles 
or sinapisms are put to the legs or feet. 

When the critical period in pernicious fever has passed, it will 
need treatment like an ordinary case of intermittent or remittent, 
according to the type which it assumes. A modification of this 
affection, sometimes called "winter fever," will be considered under 
the head of typhoid pneumonia. 



tELLOW FEVER. 137 

Typho-Malarial Fever. 

This, having had its origin in the circumstances of the late war, 
is now altogether a matter of history. It was the result of a three- 
fold causation ; the elements of which were malarial influence^ 
crowd poison, and scorbutic taint. According to the predominance 
of one or the other of these, its character in different cases was 
determined. Of the form in which the malarial element predomi- 
nated, the somewhat abrupt commencement, gastric disturbance, 
and icteroid skin and tongue, with remissions, for a while at least 
tolerably distinct, were prominent features. The lenticular spots 
of typhoid fever, and the sudamina and tympanites were often 
wanting altogether. 

A slower onset, less distinct remissions, more cerebral disturb- 
ance and diarrhoea, with epistaxis and bronchitis sometimes, but 
with both less constantly than in civil life, marked the predomi- 
nance of the typhoid pathogenetic element. Deafness was not very 
frequent, but was sometimes very well marked. The aspect of the 
countenance, and the character of the somnolence and delirium, 
were precisely the same as in ordinary typhoid fever. 

The scorbutic complication was recognizable, in the third group 
of cases, by the peculiar mental and bodily prostration which pre- 
ceded and followed the disease — the ramarkable irritability of the 
heart, the state of the gums, tendency to hemorrhage, discolora- 
tions and petechia, pallid, large and smooth tongue, and extremely 
protracted convalescence. 

Treatment. — From the above view of the hybrid and threefold 
nature of the disease, came its rational treatment. More quinine 
than in typhus, more alcohol than in remittent, more fresh vegeta- 
ble food and fruit than in either. Experience justified this plan. 

YELLOW FEVER. 

Only certain localities have ever been subject to this disease ; 
and of those, most have had it but occasionally. 

All the places which it has ever visited are upon the borders 
of the Atlantic Ocean, or its tributary waters, the Gulf of Mexico 
and the Mediteranean Sea. Although under like climatic condi- 
tions, while it is common in the West Indies and West Africa, it is 
unknown in the East Indies, the eastern shore of Africa, and the 
Pacific coast of America. 



138 YELLOW FEVEfc. 

Symptoms and Course. — With an abrupt beginning, or an in- 
distinct cold stage, with pains in the back or limbs, commencing 
often in the night, a febrile stage occurs, of long average duration; 
sometimes three days without remission. Violent cases have it 
shorter; sometimes lasting only a few hours. 

The skin, at this period, is hot and dry. Thirst is extreme ; the 
tongue is generally furred. Nausea and vomiting are common on 
the second day, with great epigastric tenderness. The bowels are 
costive ; if discharges occur they are very offensive. 

A flush of the forehead, with a fiery look of the eyes, is charac- 
teristic. Delirium is frequently present- Violent headache is 
nearly universal. 

The stage which follows this pyrexia is a sort of remission or in- 
termission. All the symptoms abate except the epigastric tender- 
ness. The flush of the face and of other portions^of the skin is 
succeeded by yellowness, which grows deeper as the disease ad- 
vances. The pulse grows slower, heat abates, respiration becomes 
natural in frequency, the patient sits up and feels better. This 
state of things lasts for a variable time, averaging about twelve 
hours. 

Sometimes convalescence now takes place. Much more often a 
third stage succeeds, of prostration or collapse. Muscular debility 
becomes great ; the pulse is rapid, irregular, and compressible ; 
the capillary circulation sluggish ; the skin deep yellow or bronzed ; 
the tongue brown ; the stomach excessively irritable. It is at this 
time that the black vomit occurs, which is pathognomonic of this 
fever. Hemorrhages may also occur from the mouth, throat, or 
bowels. The mind grows apathetic, or low muttering delirium 
exists. In bad cases, which are many, hiccough, clammy sweats, 
convulsions, and involuntary discharges precede dissolution. Death 
most frequently occurs on the fourth, fifth, or sixth day. 

When reaction from the collapse takes place, there follows a 
secondary fever of very variable duration, and which may termi- 
nate in a tedious convalescence, an almost equally prolonged 
typhoid condition, or death by exhaustion. 

Black Vomit. — This has been found, upon chemical and micro- 
scopical examination, to consist essentially of blood, altered by 
action of the fluids of the stomach. It is usually acid to test- 
paper. 



YELLOW FEVER. 139 

The urine, in yellow fever, is scanty and high colored at the be- 
ginning, and especially deficient in amount from the third to the 
fifch day. About the fourth day it becomes cloudy and deposits a 
sediment. 

Morbid Anatomy. — Congestion of the brain is not uncommon ; 
inflammation of the stomach is usual. The liver is most frequently 
dry, pale yellow, and anoemic ; but occasionally it is engorged. 
Fatty accumulation in the liver has been repeatedly observed; and 
exudation into it is asserted. The spleen is little altered; the 
kidneys are always congested. 

Diagnosis — The only doubt likely to be entertained is as to its 
identity (or that of an example of it) with bilious remittent fever. 
As already remarked, the latter is a disease of the country, in any 
warm quarter of the globe. Yellow fever is restricted geographi- 
cally, and is but seldom met with except in towns and near the sea. 
The order of stages in the two diseases is different; remittent never 
has a pyrexia lasting over twenty-four hours without mitigation. 
There is more epigastric tenderness in yellow fever. The jaun- 
diced hue of the skin is more commonly met with, and is more 
positive, in that disease. The black vomit, when it occurs, is deci- 
sive. Possibly, even probably, in a few localities, the combined 
causation of the two fevers may produce hybriclity between them. 
Immunity for a lifetime after one attack is common with yellow 
fever ; not at all so with remittent. 

Prognosis. — This is a very dangerous disease ; the deaths from 
it averaging about one for three cases. A long and moderate 
febrile paroxysm, without excessive irritation of the stomach, is 
favorable. So is the occurrence of secondary fever instead of col- 
lapse, after the remission. Black vomit is almost always a fatal 
sign. Some instances of the disease are called walking cases, be- 
cause their early symptoms are slight, only the countenance and 
pulse betraying the danger until near the end. 

Pathology and Causation. — There seems no room to doubt 
that yellow fever is a zymotic disease, whose cause is generated by 
certain local conditions. 

The conditions observed are : 1. Continued high heat ; about 
80° for one or two months. 2. Excessive moisture in the air ; a 
high dew point. 3. Vicinity to the sea, or to a large river empty- 



140 YELLOW tfEVEK, 

ing into the sea. 4. Organic, especially vegetable, matter in a 
state of decomposition. This is furnished not only by the offal, 
etc., of cities, but by decaying wharves and causeways (as at Nor- 
folk, Ya.), and by newly upturned earth. 

The contagiousness of yellow fever, from person to person, is still 
asserted by some authorities, although opposed by a great number 
of facts. A very few apparent examples of transmission by indi- 
viduals, if admitted to have occurred, are otherwise explained. 
Transportation by ships is admitted by all, because a ship may carry 
a section, as it were, of a locality, with all its conditions and at- 
mosphere. But, then, the port to which the ship goes must have 
all the conditions rife for the propagation of the disease, or its 
"germs" will not be maintained so as to cause an epidemic. When 
the disease has become endemic in a locality, the removal of as 
many of the population as possible ought to be advised. 

Treatment — No specific has been found for yellow fever, and 
no abortive treatment. All kinds of remedies have been tried for 
this in vain ; especially bleeding, calomel, and quinine. In vain 
as to cutting it short ; but in palliating and conducting it through 
its stages with safety, proper remedies are very useful. 

Yellow fever is always a terrible disease, the mortality varying 
much in different epidemics. 

Attention to all hygienic measures and rules, is most important. 
At the beginning hot drinks, warm foot-baths ; emetics, followed 
by purgatives, have proved beneficial. It is important to get the 
excreting organs to free action as early as possible. Copious warm 
enemata are useful containing turpentine. Saline drinks may be 
freely given. When the patient is very hot frequent sponging, or 
the wet sheet should be employed. 

All the result of the use of the quinine is, that it is not likely to 
do good at any early stage, but only when prostration begins to ap- 
pear ; and then in tonic or supporting, not cinchonizing doses. It 
is undoubtedly of service during convalescence. 

Attention to the stomach is demanded by urgent symptoms. Ice, 
by the mouth, is refreshing and useful. So is mineral water, or 
iced champagne, a little and often; lime-water, charcoal water, 
and hot coffee have sometimes done service in arresting vomiting. 
A mustard or spice plaster over the epigastrium, or a blister dress- 



CEREBRO-SPEtfAL FEVEK. 141 

ed "with acetate of morphia, may have an important effect upon the 
same symptoms. 

In the collapse, stimulation will be needed, by wine, brandy, or 
whisky, etc.; along with concentrated liquid food, in small amounts 
at short intervals. Hemorrhages, and typhoid symptoms must be 
treated as they arise. During convalescence quinine and iron 
should be given. 

The experiments with anti-septic and anti-zymotic substances, as 
chlorine and the sulphites, made with other affections analagous to 
yellow fever, might be properly tried with it also. 

CEREBROSPINAL FEVER. 

Synonyms. — Cerebrospinal Meningitis; Spotted Fever; Petechial 
Fever. — The name adopted above is preferred in the absence of suf- 
ficient preponderance of authority or reason in favor of either 
of the other names. The disease is a systemic disorder; not a 
mere local phlegmasia. 

History.— Often obscurely described, this disease appears to 
have been known in France in 1310 and 1482; over Europe, or 
parts of it, at various times since then. 

In the United States, its first recorded visitation was in 1806, in 
Massachusetts. Then it gradually spread through the New Eng- 
land States, New York, and Canada, from 1807 to 1812, when it 
had reached Philadelphia. After that it was met with at various 
places until 1820; but with not great frequency. Between 1848 
and 1850 it was epidemic in several of the Middle, Western, and 
Southern States, also in 1852 and 1858. Next we hear of it in 
1862-3; as it occurred in the neighborhood of Philadelphia. Since 
that time (at which cases were seen especially at Frankfort, Falls 
of Schuylkill, Manayunk, and Norristown, but only a few in the 
city) it has been observed in a number of places in Pennsylvania, 
New York, Ohio, and other States. In 1873-4 it was again quite 
prevalent. 

Symptoms and Course — The attack is nearly always sudden. 
Chilliness, terrible pain in the head, extending to the back of the 
neck, nausea and vomiting, are the earliest symptoms. Delirium 
follows ; ending not unfrequently in coma. Tetanic spasm or 
rigidity of the muscles of the back of the neck (and sometimes 
of the back and limbs), is common. Convulsions are much less so, 



142 CEREBRO-SPIKAL tfEVEB. 

but do occur, particularly in the young. Painful sensitiveness 
(hyperesthesia) of the whole surface of the body is present in 
most cases, where there is no coma. Loss of sight and hearing 
may take place during the middle period of the attack. The pulse 
is at first slow, then accelerated, but diminished in volume and 
strength. Respiration is slower than natural in most, but not in 
all cases. The tongue is usually at first white and moist ; some- 
times natural ; in prolonged cases it may become yellow or brown. 
The bowels are costive or natural ; more apt to be constipated. 

The skin has almost always at the beginning an abnormally low 
temperature. When reaction occurs it doe3 not become very hot, 
as a rule. Dryness of the surface is most common, although late 
in the attack profuse perspiration may occur. 

In a minority of the cases, though varying in proportion in dif- 
ferent epidemics, spots (petechia) appear, on the second or third 
day, or later ; on the neck, breast, or limbs ; seldom on the face. 
They are of different dimensions, from the size of a pin's head to 
three-quarters of an inch in diameter, and distinct ; but not ele- 
vated nor disappearing on pressure. Their color is red, purple, or 
black. Sometimes they remain after death. They are either con- 
gested portions of the skin, or subcutaneous extravasations 
of blood. 

The duration of fatal cases of this disease is generally short. 
Some die in three or four hours ; many within twelve or twenty- 
four hours. That much time overpassed, the danger becomes less, 
but a fatal result may still occur, even after a number of days. 
The first four days are the most perilous to life, as a rule. 

Morbid Anatomy. — The blood, during life, is found to have an 
excessive proportionate amount of fibrin and corpuscles. After 
death, when this has taken place on the first or second day, no 
anatomical changes, even in the brain, have, in several instances, 
been found. Most generally, however, the brain and spinal cord 
show some alteration. It is the pia mater especially in which con- 
gestion, at least, is nearly always present. At the base of the 
brain, most of all, is this, often with serous and plastic exudation, 
observed. The surface of the hemispheres may also be diseased; 
and, next in frequency, the pia mater of the cervical portion of the 
cord. The ventricles of the brain have usually an excess of fluid 



EPIDEMIC CEREBROSPINAL FEVER. 143 

in them ; serum, either clear or mingled with blood or pus. The 
substance of the brain is more or less injected or congested ; the 
spinal c'ord occasionally so. Softening of the brain is reported in 
protracted cases. 

No other lesion or appearance is shown to be usual in this 
disease. A few observers record the presence of rather firm fibrin- 
ous clots in the heart. 

Diagnosis. — From typhus fever, this is known by the sudden- 
ness of its onset, the early period of danger, and, in favorable 
cases, the rapid recovery ; as well as by the peculiarity of the 
eruption. From ordinary inflammation of the brain, while the 
diagnosis may be very difficult, it differs in the unexplained abrupt 
attack, severe from the start ; in the lowness of temperature dur- 
ing the first day or two ; in the early tetanic tendency ; and the 
eruption in many cases. Malignant scarlet fever resembles it con- 
siderably at the onset ; and so does the chill of pernicious inter- 
mittent. Locality and season will designate the latter ; age and 
exposure, especially the former. Fortunately, the principle of 
treatment is not essentially difierent in these affections at the stage 
which may present a doubt. 

Malignant cases may occur, when consciousness is lost, the head 
drawn back, and the train of symptoms passed, and death is reached 
at the end of twenty-four or forty-eight hours from the ushering 
in of the first symptoms. A few cases have undoubtedly occurred 
where the disease has caused death in a few hours from general 
paralysis, and occasionally without the characteristic tetanic symp- 
toms. Such are the symptoms, course and termination of cerebro- 
spinal meningitis when left unchecked and unmodified by timely 
and judicious medical skill and intelligent nursing. Fortunately 
this grave malady is amenable to medical science to an encourag- 
ing extent, and its strides may be checked, and finally crushed, 
like most epidemic diseases, by correct sanitary measures. 

Prognosis. — Favorable Signs. — Less jactitation, mind clearer, 
though pain in head and back, and tetanus continue, or only sligh- 
ly decrease. If improvement progresses, all symptoms gradually 
disappear in a few days, but convalescence is usually slow and 
tedious, and relapses are common. 

Unfavorable Signs. — When high temperature obtains, the case is 
almost uniformly fatal. Improvement, though begun if the disease 



144 EPIDEMIC CEREBROSPINAL FEVER. 

drags on, convalescence may not occur for weeks. Headache and 
opisthotonus continue. Paralysis of the psychical and motor func- 
tions causes a complicated series of symptoms, and most -of such 
cases die of gradually increasing marasmus. 

In miasmatic districts this epidemic is liable to assume an inter- 
mittent type, as a general feature, of which three forms may be no- 
ticed : 1st. As only occurring in the first stage ; one or more im- 
pressions of premonitory symptoms obtain and pass away: another 
soon follows, and immediately succeeded by full development of the 
disease. 2d. Sudden remission of symptoms; grow worse next 
day; occasionally alterations thus recur several times, in more or 
less quotidian type. 3d. And far most frequent, perfect intermis- 
sions during convalescence. Headache and stiff neck regularly 
increase for some time in quotidian type, but in the interim the 
patient feels little inconvenience. 

Individual Symptoms should be noted to make the description com- 
plete. Headache and backache may be deemed a uniform symp- 
tom throughout. Especially severe in those which terminate 
within a few hours. As long as consciousness remains headache is 
complained of spontaneously, or if asked. After the intellect is 
clouded, the moaning, restlessness and labored distresses of the 
patient seem to be fairly due to the headache and backache. While 
this epidemic prevails many are found complaining of headache 
who never come under the attack. Such cases are named abortive 
forms. Cervical and dorsal pains accompan} T , or soon succeed 
headache, and are increased by pressure on the spinal processes, 
and on the least voluntary movements. If the disease is protract- 
ed, these dorsal pains and their aggravation by movements con- 
tinue through weeks. In the extremities painful sensations occur, 
obviously neuralgic, caused by irritation of the posterior roots 
of the spinal cord, but are not uniform symptoms. These some- 
times only appear on motion of the spine, either voluntary or by 
handling. 

Hypercesthesia and Anaesthesia of the Skin. — The patient is usually 
very sensitive to the touch and any rough handling of the skin for 
the first few days, in many cases throughout, and pain enhanced 
when turned over in bed, handled or percussed. Later no reaction 
obtains, even when the skin j.s^ greatly irritated; but when the 



EPIDEMIC CEREBRO-SPINAL FEVER. 145 

patient is in a stupor there is cerebral anaesthesia. Peripheral 
anaesthesia is very rare, "while consciousness exists ; when the pa- 
tient feels irritation of the skin but little or none at all, for this 
symptom of immunity from morbid sensibility depends upon loss 
of excitability of the posterior roots, caused by inflammation. 

Tetanic Spasms are seldom absent. Head only slightly retracted 
at first ; later it forms almost a right angle with the body. 

The Respiration is affected by this high grade of distortion, but 
sometimes is relieved just before death ; but generally persists 
more or less severe till death or convalescence. 

Eliptiform Convulsions are rare, which is singular, knowing the 
widely spread exudation over the convexity of the hemispheres. 

Paralysis — Usually no actual paralysis occurs till death ; a few 
cases of hemiplegia, or paraplegia, and many where paralysis of 
the facial, oculmotor, or the abducens are observed. These are 
easily explained, and that paralysis is no more common is a sin- 
gular fact. 

The Organs of Special Sense often suffer. Blindness from kera- 
titis, from incomplete closure of the lids, the result of purulent 
infiltration along the optic nerve. Deafness is very frequent, 
chiefly caused by purulent infiltration along the auditory nerves 
to the internal ear. 

Cutaneous Eruptions, as groups of herpes vesicles, are very com- 
mon, and more rarely arythema, roseola, urticaria, petechia and 
sudamina. The frequency of exanthemata and their occasional 
symmetry is supposed to be due to irritation of the cutaneous 
nerves. 

The Fever has no regular course in cerebro-spinal meningitis. 
Few temperature curves resemble each other ; sudden leaps and 
exacerbations of brief duration often occur. The most frequent 
are exacerbations of one-half to a degree, generally of the remit- 
ting type. High temperature is expressive of great danger. 103° 
may be regarded as the maximum of heat in most cases. 

A Reabsorbing Fever of intermittent type may accompany con- 
valescence, but if such type occur the first or second week it is due 
to an interrupted progress of the meningitis. 

The pulse is little guide, as its frequency does not accord with the 
height of the fever, but often quite the reverse obtains ; usually 
the pulse is quick and resisting at the early stage of the disease. 



146 EPIDEMIC CEREBROSPINAL FEVER. 

Treatment — Great diversity of remedies and measures have 
been employed in this disease, and with an average mortality rang- 
ing from twenty-five to fifty per cent. In deciding the best means 
of treatment, we are to adapt them to those cases in which there is, 
at least, slight hope of recovery. The whole train of symptoms 
clearly indicates that the disease is meningeal inflammation of the 
brain and spinal cord in various degrees and modifications. It is 
well understood that the same cause will develop a widely different 
train of symptoms in different patients of equally diverse tempera- 
ments, and that no uniform course of measures will be readily adapt- 
ed to fulfil so diverse requirements. Hence it follows that only a 
general, but judicious line of treatment can be marked out, leaving 
it to the discernment, experience and judgment of each practi- 
tioner to select and apply' such means as each case, in its various 
stages, modifications and complications, seem to require. 

On reflection, the writer, during his forty-two years of uninter- 
rupted practice, has a vivid recollection of a great number of par- 
allel or similar cases of cerebro-spinal meningitis, dating back 
thirty years at least, and prior to the attention of the profession 
being called, by writers in Europe, to the disease as an epidemic. 

To treat a disease of this variable character, and attended with 
sudden fluctuations, and so diverse symptoms, careful discrimina- 
tion is requisite, so as to use the best means, and change at the 
proper moment, as the symptoms indicate. To do all that can be 
safely done, but not overdo, is the rule. 

Congestion of the Nerve Centres is what we have to treat, and 
this leading thought is the helm to guide us in every case, instead 
of seeking only to remove the local determination and subsequent 
inflammation. In children of five years old, in the first stage, it 
is deemed proper to give : 

#. Vini. ipicac, 3ij.; tr. aconite, gtts. x.; tr. belladonna, gtt. x.; 
peppermint water, 3iij«; glycerine, 3j. M. Dose, one teaspoonful 
every hour during fever, or once in three hours when little fever 
exists. Add gtt. xx of tr. veratrum while the fever is very high. 

Topical Applications. — In a mild form of the disease hot and 
moist applications to the feet, hands, limbs, head, neck and back 
are preferred. But when the disease has a grave form the nerve 
centres greatly suffer, and evidence of active meningeal inflamma- 



EPIDEMIC CEREBROSPINAL FEVER. 147 

tion exists ; apply ice-compresses to the head and nape of the neck 
energetically, in oiled silk bags or bladders, and pencil over the 
whole spine, three inches broad, with : #. 01. mustard and alcohol, 
aa 3j, and continue the hot applications on other parts, as before. 
On the second or third day the acute symptoms may have so far 
abated that diuretics may be specially required. For this purpose : 
R. Tr. Apis Mel. 3J.; ac. or cit. pottassa, 3J-; aqua, menth. viridis, 
3ij. Dose, a teaspoonful once in four hours, in water. 

Constipation, an almost uniform attendant, should receive early 
attention, and to the termination of the disease. One of the best 
preparations, to which no objection can be offered, and which 
fulfills various other indications, will be found in oil and turpentine 
emulsion, something like this : fy. Gum acacia, pulv., 3jss.; aqua 
menth. pip., ol. ricini, aa. gj.; spts. turp., 3ij.; syr. ipecac, glyce- 
rine, aa. 3j.; brom. pottassa, 3ii. Dose for a child, coch. min. 
every hour ; or, for an adult, coch. mag. in like manner, and aided, 
if required, by copious enema of warm water, in which tr. lobelia 
is included in doses to impress the system. That no other medi- 
cine will be required while this is being used, is obvious. Active 
catharsis is inadmissible and bad practice. 

Tetanic symptoms and trismus may require special remedies, either 
almost constantly for days, or at intervals throughout. Copious 
enema of a solution of starch in warm water, to which add : #. 
Tr. lobelia and spts. turp., aa. 3j., seldom fails to so far relax and 
hold the tetanus in abeyance, if repeated when required, as to 
render the sufferer quite safe and comfortable. But if the tetanus 
and trismus attain a grave hold upon the patient, hyd. chloral in- 
ternally, in full doses, or chloroform by inhalation, sufficient to 
overcome the emergency, are the proper means. 

Special symptoms and conditions require close attention. When 

irritation of the lungs obtains, with difficult respiration and harassing. 

cough, the application of: fy. Snuff, 3j.; lard, 3j.; make ung., 

with which annoint the chest, and give : #. Pulv. ipecac, grs. iij.; 

sugar, grs. xij.; divide into twelve powders, and give one every 

two hours. In grave cases, with great evident congestion, bathing 

with hot, strong mustard water, followed with brisk friction, and 

give : #. Anti-spasmodic tr. 3ss.; comp. tr. cajeput, 3ss.; simple 

syr. 3ij. Dose, 3ss. every half hour until reaction obtains. 

13* 



148 RELAPSING FEVER. 

Then anconite and belladonna may be resumed as follows : #. Tr. 
aconite, tr. belladonna, aa. gtt. x.: aqua menth. pip., 3ij ; coch. 
min. once in four hours. If irritation of the stomach and vomiting 
occur: #. Tr. nux vom., gtt. xv.; water, 3iv. One teaspoonful 
every fifteen minutes, keeping small pieces of ice in the patient's 
mouth, which will be received with eagerness and enjoyed, untl 
its effective sedation allays the gastric irritation, are usually the 
best means. 

Tonics, as quinine, the mineral acids and iron in heroic 
doses, especially the former, have been insisted upon from various 
credible sources. But these means should be used with great cau- 
tion in cerebro-spinal meningitis, to say the least. Stimulation 
with brandy or whisky will be required where symptoms of ex- 
haustion are present, but employed with due caution. Various 
other means at different stages will readily suggest themselves to 
the practitioner. 

If the type assumes intermittent form, treat it as such. Severe 
brain symptoms may require dry cupping on the nape of the neck 
and between the shoulders, and followed by a blister. This may 
afford marked relief. 

The diet, or a proper course of nourishment, varying and suiting 
it to the stages of the disease with great circumspection, is of vast 
and often of vital importance. We must keep in mind most promi- 
nently the fact that the system must be sustained until the specific 
cause has spent its force, as it certainly will in due time, like other 
well-known severe forms of disease, it often does. External stimula- 
tion is, also, often indicated ; by mustard, direct heat, friction 
with red pepper and brandy, or hot whisky and salt, etc. 

Cantharides (20 to 40 drops of the tincture, every hour till reac- 
tion), camphor, chloroform, and sulphite of sodium have each had 
laudation from some who have used them in prostration. 

RELAPSING FEVER. 

Synonym. — Famine Fever. 

Symptoms and Course. — Beginning rather abruptly, with chilli- 
ness, headache, and vomiting, with a white moist tongue, tender- 
ness of the epigastrium, and constipation, the fever rises soon to a 
considerable height, with a full and frequent pulse, and a tempera- 
ture on the second day of 104° or 105° F. Severe pains in the 



TYPHUS FEVEK. 149 

back and limbs occur ; sometimes delirium. This exacerbation 
continues without distinct remission for from five to seven or eight 
days. Then a copious perspiration occurs, the temperature falls 
rapidly to 98°, or sometimes even less ; and all the symptoms sub- 
side. The patient seems to be well. In about a week, however, 
(on or near the fourteenth day of the attack) a relapse takes place, 
which is characteristic of the disease. Its symptoms are much the 
same as those of the first paroxysm ; its duration, from three to 
eight days. 

Prognosis — In Great Britain, the deaths have numbered about 
one in forty cases ; in Russia, ten or eleven per cent. In the 
Philadelphia Hospital, in 1871, of 517 cases, eighty died ; the 
mortality being much the largest among colored patients. 

Pathology and Causation. — This appears to be a specific 
disease. Its prevalence among the destitute of large cities in 
Europe has caused it to receive, at times, the name of "famine 
fever." Autopsic examination has shown a remarkable enlarge- 
ment of the spleen in many cases ; and alterations of the blood- 
corpuscles have been observed during life. It is believed to be 
contagious by many physicians, but did not clearly manifest that 
property in the Philadelphia Hospital. 

Treatment. — A mild saline cathartic is proper at the beginning 
of the attack ; followed by cooling diaphoretics, as solution of 
citrate of potassium or acetate of ammonium. When headache is 
severe, cups may be applied to the back of the neck. After the 
crisis of defervescence has occurred, quinine may be given in mod- 
erate doses, until the relapse. During the third week, a consider- 
able number of patients will require support, with beef-tea and 
milk; sometimes, also, alcoholic stimulants, tonics, etc. 

TYPHUS FEVER. 

Synonyms. — Ship Fever; Camp Fever; Jail Fever. 

Symptoms and Course. — For a day or two, premonitory weak- 
ness, headache, and loss of appetite occur. Then a cold stage, 
of variable distinctness, begins the attack. In rare instances, it is 
said that death takes place in this, without reaction. Much more 
commonly, fever follows; with severe headache, great heat of skin, 
pulse 120 (110 to 130), but compressible, tongue whitish or yel- 
lowish, bowels costive. Delirium is common, especially at night. 



150 TYPHUS FEVER. 

The temperature in the axilla is from 102° to 108° ; generally, 
after the third day, 105°-6° in the morning, 106°-7° in the even- 
ing. Muscular debility is very decided. 

For a number of days this condition lasts ; the patient l^ng in 
a stupid half-sleep much of the time, muttering to himself, easily 
roused, but soon lapsing again ; the face having a dusky flush 
of redness. Hardness of hearing is present in most cases. Posi- 
tive coma is a very bad prognostic, but is not infrequent. Sup- 
pression of urine may take place in the worst cases ; retention 
occurs in many severe ones. The tongue grows darker as the 
attack progresses ; brown, even black ; often cracked or fissured ; 
and it as well as the teeth may be covered with sordes. 

Towards the end of the first week, in most cases, a rash appears, 
of little and numerous red papulae (miliary eruption), all over the 
chest, abdomen, and upper parts of the limbs. These are accom- 
panied by sudamina (minute vesicles) in many instances, by petechial 
in a few. Sometimes a strong odor comes from the body. 

The urine is scanty. Generally it contains an excess of urea 
and uric acid, with a deficiency of the chlorides. Sometimes there 
is actually less than the normal amount of urea eliminated ; when 
excreta may be supposed to accumulate in the blood, promoting 
coma. Costiveness is the general rule in typhus. 

The dicrotous or double pulse, and subsultus or twitching of the 
tendons at the wrist, are common. Weakness of the impulse 
of the heart is often noticeable ; sometimes so much so as to justify 
Dr. Stokes' diagnosis of "typhous softening." Hypostatic pneu- 
monia (i. e., beginning with passive congestion of the lungs pos- 
teriorly) is the most frequent complication of the fever. 

The duration of an attack of typhus is generally three weeks. 
Some writers speak of its typical duration as fourteen days. The 
critical period is about the eleventh day ; after which defervescence 
(the decline of the fever) may be looked for. Occasionally death 
may take place within five days, or recovery within fifteen, from 
the commencement. 

Morbid Anatomy.— Absence of lesion of the solids has been 
repeatedly noticed. The blood is always altered during life ; after 
the early stage, it is less coagulable and darker in color than in 



TYPHUS FEVER. 151 

health. Passive congestion in various organs is observed, as in the 
lungs, brain, liver, etc., but without anything characteristic. 

Pathology and Causation. — No disease affords more reason for 
pronouncing it a disease of the blood than typhus. Its cause, de- 
monstrably in many cases, is ochlesis or crowd poison ; the effluvia 
from human bodies, accumulated, especially in cold weather, in 
small and ill-built dwellings of the poor, and most of all in filthy 
towns, ships, jails, or camps, Having once. been thus generated, 
it becomes contagious : one patient having in his morbid emana- 
tions the poisoning power of a whole crowd. Yet the contagion is 
not very strong; many who are exposed escaping the disease. 

Diagnosis. — After the first two or three days (during which 
there may well be a doubt as to its character) the only probable 
question will be between typhus and typhoid fever. All medical 
authorities are not yet agreed as to the non-identity of the two 
forms of slow continued fever. A large majority, however, regard 
them as quite distinguishable during life, and separated pathologi- 
cally by the absence in typhus of the morbid alterations of Peyer's 
glands, and those of the mesentery, characteristic of typhoid fever. 
Under the head of Typhoid Fever, the clinical differences will be 
enumerated. "* 

Prognosis.— Murchison states the mortality in the hospitals 
of Great Britain, from typhus, to be one death in five cases. 
Chejme and others in private practice have found it but one in 
twenty or more. Probably one in ten or fifteen would be a fair 
general estimate. Bad signs are, great feebleness or extreme ra- 
pidity of the pulse ; profound coma ; hiccough ; suppression of the 
urine ; involuntary defecation. Pneumonia complicating the at- 
tack increases its danger. 

Treatment — More than half the cases of typhus require alco- 
holic stimulation, as well as concentrated nourishment after the 
fourth day. But not all cases. 

We may begin the treatment of an ordinary case of typhus with 
a mild laxative — e. g., a moderate dose of solution of citrate of mag- 
nesium, on the second day. The diet at first may be of gruel, 
toast-water, etc.; but very soon must milk and beef-tea or chicken 
or mutton broth (or an alternation of these) be given to support 
the strength. Before the first week is out, half the cases will need 



152 TYPHUS FEVER. 

wine in moderation ; some, brancty or whisky. In the second and 
third week, more than half the cases will require steady support 
of a positive kind. In such instances, the proper routine is, a 
tablespoonful of brandy or whisky punch (one part of spirit to 
three, two, or one of milk) every two hours, and, the alternate 
hours, a tablespoonful or two of beef-essence or beef-tea. 

Of medicines, quinine has had the most extended trial in typhus. 
It acts well as a tonic, in one or two grain doses, four or five times 
daily, after defervescence has begun : i. e., after the tenth or 
twelfth day usually. Dr. Dundas' plan of treating typhus early 
with large doses of quinine is futile and even dangerous. 

Mineral acids have acquired much reputation in typhus. Nitro- 
muriatic has been known to produce an excellent efiect in the de- 
pression of the middle stage. Large doses are not required ; but 
the acid should be given several times in the day. Some prefer 
dilute nitric acid. Chlorine water is lauded highly by some. The 
sulphite of sodium is worthy of trial. 

But the great point of skill will be to determine when and how 
far to stimulate. Delirium favors the probability of its being 
needed ; especially a low, muttering delirium. Of course a very 
feeble pulse indicates it. On trial, if the pulse grows slower, the 
skin more moist, and the restlessness or delirium is quieted, the 
stimulus has done good, and should be continued. If, on the con- 
trary, a more hurried or a harder pulse follow, with heat of head 
and dryness of skin, and wilder delirium or deeper stupor, it 
should be stopped, for awhile at least, or, if given, be diminished 
in amount. 

Catheterism may be needed for retention of urine. Inquiry and 
inspection should determine every day the state of the bladder. 
Constipation, through the attack, may be overcome by enemata, or 
by small doses of oil, Rochelle salt, or other mixed laxatives. 

When the coma is very deep, a blister to the back of the neck 
may do good ; as well as sinapisms to the extremities. Great heat 
of the head may render proper, especially in the first week, the 
application of cold water to the head. Sponging the whole body 
daily (best at night) with whisky and water, warmed, is extremely 
comforting and beneficial. 

Hypostatic pneumonia, in typhus, cannot be treated actively. 
Dry cups, between the shoulders, and a .blister upon the breast, 



TYPHOID FEVER. 153 

are about all the special treatment allowable. It is, however, pos- 
sible generally to prevent hypostatic pneumonia, by not permitting 
the patient ever to lie for many hours together upon his back. 
Let hira be turned, once in a while, upon one or the other side. 
Stimulating fomentations are often very beneficial to the chest. 

Prophylaxis — Thorough ventilation is the one security against 
the generation of typhus fever; and this is capable also of almost 
disarming its contagion. Anti-septics and disinfectants are indi- 
cated throughout the course of typhus fever. 



TYPHOID FEVER. 

Synonyms. — Typhoid Fever; Enteric Fever; Pythogenic Fever; 
Abdominal Typhus. 

Varieties. — Remarkable differences obtain in degree, severity, 
and in prominent symptoms. Occasionally no characteristic symp- 
toms are manifest, and an early diagnosis is difficult : 

1. The mild form, including the abortive, which ends the second 
or third week, and cases of the nature of febricula. 

2. The grave form, which, as prominent symptoms obtain, is sub- 
divided into : inflammatory, ataxic, adynamic, irritative, abdominal, 
thoracic, and hemorrhagic. 

3. The insidious or latent form, also called ambulatory, because 
the patient may walk about during the whole course. Sudden 
death may occur in this kind from perforation or hemorrhage. 

4. Infantile remittent fever, and gastric or bilious fever, as they 
are usually termed, are often merely modified typhoid fever. 

Symptoms and Course. — After a more gradual approach than 
that of any other fever, with languor and debility, anorexia and 
headache, for several days — bleeding at the nose, and a bronchial 
cough are almost pathognomonic early symptoms. The patient 
takes to bed, with fever of considerable violence. The face ac- 
quires a dark purple flush. He lies dozing, perhaps muttering. 



154 



TYPHOID FEVER. 



unless disturbed, all day ; but is more or less wakeful and delirious 
at night. Hardness of bearing is common from the middle of the 
second week. Swelling of the belly (tympanites) comes on towards 
the end of the first week ; diarrhoea about the same time. Rose- 
colored lenticular spots (taches rouges), disappearing on pressure, 
are discoverable, few in number, and on the abdomen only, toward 
the end of the second week ; they continue a week or two. Ten- 
derness on pressure in the right iliac region, with gurgling under 
the hand, generally exists. Sudamina over the chest are not 
unusual. The duration of the typhoid pyrexia is seldom, from the 
start, much less than two weeks, and it is often more ; the whole 
attack of typhoid fever may be protracted, as I have seen it, to two 
or three months. One month may be considered the average time, 
from going to bed to leaving it convalescent. 

Late symptoms in severe cases are, the dicrotous pulse, subsul- 
tus tendinum, retention (or suppression) of urine, hemorrhage 
from the bowels ; and, if death be imminent, hiccough, cold sweats, 
involuntary discharges. 

In protracted cases, great emaciation and bed-sores may super- 
vene. Even during convalescence, abscesses in various parts of the 

body may give trouble. These 
usually affect the glands or con- 
nective tissue, but may occasion- 
ally involve the long bones. 

Danger of perforation of the 
intestine, from deep ulceration of 
the glands of Peyer. exists always 
after the first week, until late in 
convalescence. Patients out of 
bed for a week or two have some- 
times died, after imprudence, from 
Ulceration of glands of Peyer. this cause. The occurrence of per- 
foration is recognized by symptoms of severe peritonitis, with col- 
lapse. The result of this is almost inevitably fatal ; the only 
recorded exception being reported by Prof. G. B. Wood. 

Temperature. — This has, of late, been made a special study in 
typhoid fever. The rise from 98.5° (the normal degree) is gradual, 
during the first four or five days ; reaching 104° on the evening 




TYPHOID FEVER. 155 

of the latter; sometimes 104.5°. An attack of disease in which 
on the second day the heat in the axilla is as high as 10-4°, is not 
typhoid fever ; and the same exclusion applies if from the fourth 
to the eleventh day the temperature falls below 103°. A differ- 
ence of 1° or 1.5° between morning and evening (greatest heat, 
the latter) is usual ; the reverse is not a good sign. Toward the 
end of the second week, lowering of the heat below 103° is always 
favorable; persistence at 104°, 105°, or 106° shows a severe case; 
the higher the worse. Sudden increase of temperature indicates 
a complicating inflammation ; as pneumonia. 

Discharges. — Liquidity of the stools is a characteristic of this 
disease, even if there be but one daily. Generally, after the mid- 
dle of the first week, there are two or three passages, brownish 
with a slight yellowish tinge, every day. From the very beginning 
of the attack, the bowels are unusually susceptible to the action 
of purgatives ; a teaspoonful of castor oil operating readily. Ex- 
cessive diarrhoea, at a middle or late stage, not unfrequently adds 
to the prostration of the patient. Hemorrhage from the bowels, 
when it occurs, wr most apt to be met with in the second or third 
week. 

The urine, through the attack, is commonly scanty, high-colored, 
excessive in the amount of urea, deficient in the chlorides, and 
sometimes albuminous in severe cases. 

Complications. — Pneumonia, especially the hypostatic form (as 
in typhus) is the most frequent. It has been, by some writers, 
denied that true pneumonitis, anything more than passive conges- 
tion, occurs in these cases. But, in the analogous instance of 
typho-malarial fever, especially when the scorbutic diathesis was 
also present, I have seen, after death, more than once suppuration, 
as well as hepatization, confined altogether to the posterior portions 
of both lungs. I do not doubt the same happening in typhoid as 
well as in typhus fever. 

Inflammation of the brain may complicate typhoid, more often than 
typhus ; but still it is not common. 

Peritonitis follows always when perforation of the ileum takes 
place. Examples of its occurrence without that accident are said 
to have been, though very rarely, observed. 



156 TYPHOID FEVER. 

Sequels. — Prolonged debility, or a very slow convalescence, is 
common. The mental faculties are sometimes enfeebled for weeks 
or months. Paralysis is an occasional sequela. Abscesses have 
been mentioned. Periostitis, followed by necrosis, of the tibia, 
femur, or humerus, may happen. Perforation of the bowel may, 
as already stated, occur after convalescence has seemed to be 
established. 

Morbid Anatomy. — Omitting variable and unessential or occa- 
sional appearances, the parts characteristically affected in typhoid 
fever are, the agminated glands or patches of Peyer in the small 
intestine, the mesenteric glands, and the speen. Careful study 
of Peyer's glands, by many observers, has shown that, at first, the 
glands thicken and become elevated from one to three lilies above 
the membrane around them. They are generally at this time red- 
dened ; but with variable depth of hue. Sometimes, after this, a 
sort of induration occurs ; in other 

tion affects many, though not all, B awma ^' MM ^' l ' ll ' w| ™Mi^^^ j ;;;;g 
of the altered glands ; and this pro- diagram of a typhoid ulcer 

,-i -i -j of the Intestine.— a. Epithelial 

cess may go on until, as above said, hning< 6 _ Submucou8 ti Le. c. 

it may perforate all the COatS of the Muscular coat. d. Peritoneum. 

intestine. This, however, is excep- 
tional. The healing of the ulcers by granulation is the general 

rule. 

The solitary closed glands of the small intestine are also commonly 
enlarged, and often softened or ulcerated. The mesenteric glands 
are almost uniformly enlarged, congested, and softened ; occasion- 
ally they suppurate. 

The muscles, especially the recti abdominis, in protracted cases, 
have been shown to undergo a granular, or sometimes a waxy or 
amyloid degeneration; resulting, in the rectus, occasionally, in 
rupture of its fibres. 

Pathology. — Typhoid fever is believed by most authorities to 
be a general or systemic disorder, with a characteristic secondary 
local lesion in the intestines. How far the matter deposited in the 
patches of Peyer before ulceration is specific, is a question. That 
an inherent predisposition to the disease exists in many persons, 
analogous to the tuberculous, gouty, and rheumatic diatheses, seems 
very probable. 



^^^^^^^^"^" 



TYPHOID FEVER. 157 

Another view is, that the affection of the intestine is primary ; 
and that the "typhoid" symptoms result from the absorption into 
the blood of morbid, putrescent material from the glands of Peyer, 
producing a septcemia or ichorcemia. 

Causation. — More doubt exists as to this in typhoid fever than 
in any other common disorder. Depressing causes of all kinds 
seem to promote it ; foul air, removal from home, fatigue, anxiety, 
etc. Yet it will occur in the entire absence of all such causes. 
No locality limits it; all climates allow it ; from the Arctic regions 
to those bordering upon the tropical ; from the cities of the East 
to the Rocky Mountains. The "mountain fever" of hunters in 
the far West was found in the autopsies of Dr. Hammond to 
present the lesions of Peyer's and the mesenteric glands. 

Such universality is very much in the way of the "pythogenic" 
theory of Murchison (i. e., its reference always to foul air, as that 
of sewers), or that of Bucld, that its only cause is a specific matter, 
passed from the bowels of those having it, and, by water or air, 
conveyed into the systems of others. 

Contagion of this kind is, nevertheless, widely believed in now, 
especially in England. Some facts asserted in proof of it are hard 
to explain without admitting such a mode of propagation (e. g., by 
the discharges of a patient getting into a well, etc., so as to con- 
taminate drinking water, or, sometimes, even milk). But many 
cases allow of no such explanation; most of all those occurring in 
the open country. 

Typhoid fever is rarest in old age ; not frequent in childhood ; 
most common between fifteen and thirty years. Few have it under 
ten or over forty ; almost none beyond fifty. It scarcely ever 
(relapses apart) occurs a second time in the same person. 

Diagnosis. — From remittent fever, typhoid is known by the ab- 
sence of vomiting and sallowness of the skin, the slower onset, 
more protracted course, the hebetude or mental dullness and drowsi- 
ness, and the abdominal symptoms. 

The chief signs of typhoid fever are pyrexia, with the peculiar 
course of temperature, frontal headache, the abdominal symptoms, and 
enlarged spleen, a peculiar eruption, followed by prostration, delirium, 
epistaxis, intestinal hemorrhage, etc. 



158 TYPHOID FEVER. 

From typhus fever, the distinctive points are as follows : 

IN TYPHUS : IN TYPHOID : 

No epistaxis or bronchitis ; Epistaxis and bronchitis ; 

Bowels constipated ; Diarrhoea ; 

Belly seldom tympanitic ; Tympanites, gurgling, etc.; 

Miliary eruption 5th to 7th day; Lenticular rose spots; 

Progress moderately slow ; Progress very slow ; 

Death often within ten days ; Death rarely within fourteen days ; 

Countenance dusky red ; Countenance purplish red ; 

Causation mostly obvious ; Origin obscure ; 

Anatomy not peculiar; Lesions characteristic. 

Cases called "febricula," or "irritative fever," (formerly "syno- 
chus") are described by some writers, and met with once in a 
while in practice, which give a good deal of trouble in diagnosis. 
Some of these, probably most of them, are mild examples of ty- 
phoid fever. 

Prognosis. — The mortality from this disease varies greatly under 
different circumstances and treatment. The possibility of perfora- 
tion of the ulcerated bowel gives an element of uncertainty to 
every case. Probably one death in twenty cases will represent its 
average mortality. The favorable and unfavorable symptoms, other 
than those common to typhus or other febrile affections, have been 
indicated sufficiently already, in our account of the disease. The 
state of the tongue especially at the period of defervescence (end 
of second week, about) should always be noticed, as it aids our 
observation of the abdominal symptoms in concluding upon the 
progress of the intestinal lesion. 

Treatment. — Typhoid fever is admitted to be self-limited to the 
expenditure of the specific poison which causes it. Having its seat 
in the glands of Peyer, to which the contagion seems to have pri- 
mary affinity, and where it multiplies, is absorbed into the system 
and becomes a systematic trouble. No cutting short of it would seem 
possible. We must conduct the patient through the process of the 
malady as safely as possible, is the rationale. Can we medicate 
the glands of Peyer ? is the question naturally presenting, and the 
diseased process in them being also symptomatic, its palliation only 
appears to be indicated. 



TYPHOID FEVER. 159 

For this, little medication, perhaps none, will suffice, with proper 
diet, good nursing and proper sanitary regulation, in many cases. 
Yet this course will not always suffice or be safe. The simple pal- 
liative course of treatment has been pursued with very successful 
results. This may be briefly stated about as follows : 

In the first few days, if the bowels are costive, small doses 
of castor oil and turpentine emulsion, at intervals of two to four 
hours until it has a laxative effect. The turpentine seems to have 
a specific salutary effect upon the glands of Peyer, and in checking 
the specific contagion. During the first ten or twelve days, while 
the fever is highest, the tongue furred and often dry, the skin hot 
and no perspiration, apply tincture iodine twice daily over the 
right illiac and hippochondric region, followed by hop fomenta- 
tions ; small doses of ipecacuanha and leptandrin, to excite favor- 
able secretions. At the same time, spiritus mindereri (liquor am- 
monii acetatis) in tablespoonful doses (diluted) every two or three 
hours, from noon till midnight, as a diaphoretic. The whole 
cutaneous surface should be sponged frequently with warm alkaline 
water, to cool the body and promote cutaneous action. 

Liquid food is necessar}^ from the first. Oatmeal gruel, toast- 
water, rice-water, the first three or four days ; then cream or milk 
may be added, one or two tablespoonfuls every two or three hours. 
Less than half the cases of typhoid fever require alcoholic stimula- 
tion at any stage ; not more than one-fourth of the cases need it 
before the middle of the second week, when the fever begins to 
decline. After that time, many require it, first, wine whey, half a 
wine-glassful about every three hours ; later, when weaker, brandy 
or whisky punch — a tablespoonful of whisky, for instance, every 
four, three, or two hours, sometimes every hour, with the same or 
twice as much of milk. Beef-tea is indispensable in nearly all 
cases, from the second week. It may alternate with punch, hour 
by hour. As in typhus, a patient prostrated with severe typhoid 
fever should be waked from sleep to take the required nourishment, 
night and day ; otherwise he will sink for want of it. 

Quinine has no place as a curative of this fever. It is useful as 
a tonic, after the critical period of passing the height of the fever ; 
not more than eight or ten grains (in one or two grain doses) in 
twenty-four hours. 



160 TYPHOID FEVER. 

In the first ten days, headache and heat of the head may call 
for the application of cold to it ; sometimes for dry cups to the tem- 
ples or back of the neck. Dryness and heat of the surface of the 
body may be best allayed by sponging all over (one part only un- 
covered at a time) with tepid whisky and water. This operation, 
done in the evening, will promote sleep. Recently, cool or cold 
baths have been used (sometimes with success) to reduce the ex- 
cessive temperature (hyperpyrexia) of this and other forms of 
fever ; the patient, when the heat in the axilla reaches 104° or 
106° F , being immersed for ten minutes once or twice daily in 
water at 70° F. Such a practice requires judgment in its use, and 
can hardly be regarded as free from danger. 

Great tenderness of the abdomen may be treated by application 
of large poultices of hot mush, with which one-fourth part of mus- 
tard has been stirred. Diarrhoea being a symptom of the disease, 
it needs not to be checked unless the passages number more than 
three or four a day, or are uncommonly copious. Then, a pill 
of tannic acid and opium ( 3 grs. of the former to gr. J of the 
latter), pro re nata — or small doses of paregoric or laudanum, will 
generally reduce it. Rarely is it necessary to use laudanum and 
starch enemata, or to add tannic acid to opium in pill. Hemorr- 
hage from the bowels is not apt to continue long, or to be danger- 
ous. If it should, astringents, by enema or by the mouth, must 
be used. 

Shall we attempt to medicate the affection of the glands of Peyer ? 
This also being symptomatic, its palliation only appears to be in- 
dicated. No special treatment for it is demanded in mild ordinary 
cases. But if, after the tenth or twelfth day, the defervescence does 
not take place, and restlessness is great, with abdominal tender- 
ness, a dry tongue, and considerable diarrhoea, oil of turpentine is 
recommended by authority and experience. The dose should be 
not more than ten drops four times daily, in mucilage, with a few 
drops of laudanum, and a teaspoonful of glycerine to conceal the 
taste. Nitrate of silver is used instead by some. 

Attention to the state of the bladder, day by day, to prevent or 
relieve retention of the urine, is important. Long protracted cases 
may demand a great deal of care to avoid severe bed-sores. In 
anticipation of these when threatened, frequent changes of posi- 



CHOLERA. 161 

tion should be made, and the parts should be bathed with whisky, 
spirits of camphor mixed with olive oil or lard oil, or soap liniment. 
The bed-clothes must be kept smooth under the person. Adjust- 
ment of pillows, with the addition of small ones made for the pur- 
pose, may do much. When a part is unavoidably pressed upon, 
it may be protected by a piece of kid spread smoothly with soap 
plaster. Actual excoriations must be treated like ulcers — with 
simple cerate, lime-water, poultices, adhesive plaster, etc., accord- 
ing to their condition. 

In the majority of cases of typhoid it is the symptomatic treatment 
which calls for particular attention. The abdominal symptoms are 
the most troublesome, as a rule. The application of heat and 
moisture over the whole surface of the abdomen, assiduously and 
from an early period, alternating hop fomentations with poultices 
and cloths wrung out of hot water, whisky, or vinegar. This both 
prevents and relieves pain, tympanites, etc. 

There are many other means and measures which will be readily 
suggested to the practitioner, as individual symptoms arise, and 
which it is not necessary to name in detail. We must answer in- 
dications as they present, and not follow any preconceived notions 
or fixed rule. 

During convalescence much careful supervision will be required, 
especially as to proper food, and aperients. The diet must be very 
gradually improved, and only taken in moderation. At this period 
good wine is very valuable. If an aperient is needed, a small dose 
of castor oil, or a simple enema answers best. Tonics and change 
of air are very beneficial. Great prudence must be enjoined until 
health is perfectly regained. 

CHOLERA. 

Synonyms. — Epidemic, Asiatic, Algia, or Malignant Cholera ; Cholera 
Asphyxia. 

Symptoms and Course. — Premonitory diarrhoea, mostly painless 
and watery, occurs in most, but not in all cases. Its duration 
varies from an hour or two to two or three days. The worst epi- 
demics of cholera, however, have been marked by some cases 
of fearful rapidity. In India, in a few instances, death has result- 
ed by collapse in ten minutes. 



162 CHOLERA. 

Commonly, the diarrhoea increases in frequency and copiousness, 
and, in a few hours, vomiting commences. The discharges are 
colorless or "rice-water" like, and are spirted out with spasmodic 
force. The skin grows cold by degrees, and great debility comes 
on ; with cramps in all the limbs, usually. 

If not checked, collapse arrives ; with intense thirst, oppression 
in breathing, loss of voice, disappearance of the pulse, suppression 
of urine, cold, blue, and shrunken skin, sometimes bathed in sweat, 
and, at last, cold breath ; ending in death. This occurs, on the 
average, in about eighteen honrs. 

When reaction takes place, recovery may immediately become 
complete ; or, a low fever may supervene. The termination of this 
may be in death within a few days, or recovery in a week or two. 

Appearances after Death. — Rigidity occurs soon ; sometimes in less 
than an hour; generally within two hours. Startling movements 
of the corpse have been several times noticed ; as of a patient, 
dead with cholera, slowly, lifting both hands over the chest and 
joining them; opening the eyes and rolling them downwards, etc. 
Increased heat of the body, cold during the attack, has been some- 
times observed after death. Internally, several of the great organs, 
the brain, spleen, and kidneys at least, are commonly gorged with 
blood. So are the right cavities of the heart ; but the left side 
of the heart is empty or with but little blood, and firmly contracted. 
The lungs are almost bloodless. The liver varies in appearance ; 
but the gall-bladder is almost always full of bile. The urinary blad- 
der is, constantly, greatly contracted. The stomach and intestinal 
canal are congested and swollen ; the late Prof. Horner observed 
the frequent throwing off of the "epithelial" lining of the canal; 
Bohm, of Germany, confirmed this ; Drs. Parkes, Grull, and Lind- 
say assert it to be a post-mortem occurrence.* The intestinal glands 
are found considerably enlarged. The blood has been carefully ex- 
amined by Drs. Garrod, Schmidt of Dorpat, and others, f Its 
water and salts transude into the alimentary canal, with some 
of the albumen and fibrin ; also the contents of the blood-cells tran- 
sude into the serum. The blood drawn from a vein during life is 
dark, thick, and tarry, scarcely capable of flowing. 

* Edinburgh Med. and Surg, Journal, Jan, 1855, 
t Brit, and For, Medico-Chirurg. Rev., July,[1854. 



CHOLERA. 163 

Schmidt found the amount of oxygen in the blood-corpuscles less 
than half the normal proportion. The blood is acid sometimes in 
cholera ; the reverse of its natural reaction. 

The ganglia of the "sympathetic" system have been often exam- 
ined, and are frequently changed in appearance ; congested, soft- 
ened, altered in color ; but no special change has been shown to 
belong to them in cholera. 

Diagnosis. — Common cholera morbus, when severe, resembles 
epidemic cholera so much as to be easily mistaken for it. The 
collapsed stage of the one, preceding death, is almost identical in 
appearance with collapse of the other. But cholera morbus is 
caused by some irritant of the stomach and bowels, and is clearly 
an affection of those organs, not a toxamiia or systemic disorder ; it is 
sporadic, not epidemic; in it the discharges are always bilious at first, 
and mostly so to the last ; collapse in any degree is rare, and death, 
under judicious treatment, very uncommon. In all these things, 
it differs greatly from Asiatic cholera. Tartar emetic will produce 
effects closely analogous^o cholera when given in too large doses, 
or lesser ones too long continued. 

History.- -Cholera must have existed in India for an indefinite 
time. From 1781-2 dates its extended prevalence, in a most de- 
structive form ; at Calcutta, in Madras, on the Coromandel coast, 
and in Ceylon. 

In August, 1817, Jessore was the birth-place of the first great 
migratory epidemic. Thence it spread gradually through Western 
Asia into Europe ; reaching England in 1831. In 1832 it first 
visited America ; afterwards, it prevailed to a greater or less ex- 
tent in this country in 1833, 1819, 1850, 1854, 1865, and 1866. In 
these and other years, most parts of the world have in turn been 
invaded by this pestilence, which, except in India, seldom con- 
tinues long at a time in one place. 

Causation. — As to this, all cannot yet be known. But it is clear 

that the cholera must have a specific, material, migratory cause. 

Dr. G. B. Wood, Dr. Austin Flint, Dr. Snow, of Providence, and 

some foreign authorities, for example, Dr. Southwood Smith, "the 

father of modern sanitary reform," have believed that cholera is 

not personally contagious. Yet its contagiousness, through the stools 

of patients, is maintained by such high authorities as Dr. W. Budd 

14* 



164 CHOLERA. 

and others in England, and by Prof. A. Stille, Dr. A. N. Bell, and 
others in this country. 

In Europe and the United States, as well as in India, influences 
belonging to closely aggregated communities have always been 
observed to display a power to propagate cholera. It comes most 
often, stays longest, and is most destructive, in the densest and 
filthiest cities, and in the worst quarters of those cities. 

Very important testimony exists as to the influence of the drink- 
ing water of localities. Dr. Snow, of England, asserted the theory 
that this was the almost universal medium of its propagation. All 
such testimony is still available in regard to the propagating and 
extending power of animal contamination. 

The theory at present most in vogue, in regard to the propaga- 
tions and extensions of cholera, is based upon the observations 
and reasonings of Pettenkofer and Thiersch. According to this 
view, the specific cause of cholera either exists in the "rice-water" 
discharges, or is formed by a process of change in them after 
evacuation. This specific cause, then, is transmitted from a cholera 
patient to other persons, mainly by water-courses, above or under 
the ground ; sometimes, possibly, in the form of dry dust, through 
the air. This theory points especially to the importance of disin- 
fection of cholera stools as soon as they are passed; a measure of pre- 
caution amply sustained upon general grounds independently 
of the theory. 

Sanitary Police includes the most available measures for the 
prevention of cholera in any place For this, the measures re- 
quired are obvious, and familiar. The thorough and frequent 
cleansing of all streets, alleys, courts, wharves, and vessels, pri- 
vate and public buildings, and empty lots ; the abatement of all 
nuisances ; daily removal of offal ; efficient sewerage ; and conser- 
vancy, as the cleansing, ventilation, and disinfection of cesspools 
and water-closets. Among all signs of danger of the location 
of cholera, none is more significant than the privy odor. Let it be 
everywhere annihilated. Lime, charcoal, dry earth, chloride of 
lime, Labarraque's chloride of soda, carbolic acid, liquid coal tar, 
chloride of zinc, and sulphate of iron are the most available 
of disinfectants. 

The fresh white-washing of cellars is useful; thorough ventila- 
tion and drying of them, and of all parts of habitations, still more 



TREATMENT OF CHOLERA. 165 

so. Chloride of lime may be placed in a saucer, in any suspected 
room or other locality in a house. The same in the solid form, or 
solution of green vitriol, may be thrown daily into a foul privy ; 
and, during cholera time, especially in the case of patients with 
the disease, every water-closet and vessel used may and should be 
disinfected constantly, by a dilute solution of chloride of zinc, 
chloride of soda, permanganate of potassium, or carbolic acid. 
The immediate removal of all discharges from the sick-room, their 
disinfection, and transportation to the safest possible place of elim- 
ination, ought to be imperatively maintained. All foul clothing 
must be properly washed, or, if very bad, disinfected or burned. 

Treatment. — To give all the methods of management proposed 
for cholera, would occupy too much space. We shall merely 
enumerate those which have attracted the most attention. 

1. Bleeding. — This was largely practiced in India, in 1818-1825, 
by Corbyn, Scott, Annesley, and others. It is now, however, en- 
tirely out of use. 

2. Calomel. — This was tn old East Indian remedy. Suggested by 
the almost universal absence of bile in the discharges, which was 
thought to indicate the need of stimulation of the torpid liver, his 
argument in its favor, from the absence of bile in the stools, is 
rebutted by the fact of its abundance in the gall-bladder; while 
the clinical experience quoted for its success is accounted for by 
the addition to it, almost always, of opium, in the prescription. 
The success with it, even then, was a failure. 

3. Saline Treatment. — Dr. Stevens, of Jamaica, proposed this, 
upon the view that the main pathological element in cholera was 
the loss of salts from the blood in the discharges. After the gen- 
eral failure of saline solutions (of common salt, carbonate and 
phosphate of sodium, etc.), given by the mouth, had been con- 
ceded, Dr. Macintosh, of Edinburgh, and others, tried the method 
of injection into the veins (half an ounce of common salt, and 
four scruples of sesquicarbonate of sodium, dissolved in ten pints 
of water, at 105° to 120° Fahrenheit). Under this plan, resorted 
to during collapse, of 156 patients, only twenty-five recovered. 
Remarkable improvement, almost like a resurrection, appeared in 
several, who afterwards fell again into collapse, and died. The 
suggestion has been recently made, that it may have been the 



166 TEEATMENT OF CHOLEEA. 

temperature of the injected liquid which produced the benefit, so 
promising and yet transient. 

4. Eliminative Treatment. — Dr. George Johnson, of London, has 
urged this with especial vigor. The castor-oil medication of chol- 
era owes its trial to him. A prominent idea with him is, that the 
general collapse is due especially to anaemia of the lungs, owing 
to spasmodic contraction of the pulmonary artery and its branches. 
But the essential feature of Dr. Johnson's pathology is the opin- 
ion that, the disease being toxemic, a morbid poison exists which 
must be eliminated from the blood ; and that the discharges are the 
media of this elimination. Therefore, the vomiting and diarrhoea 
are salutary or relieving ; and ought to be rather encouraged than 
checked. He repudiates the commonly accepted belief, that "pre- 
monitory diarrhoea" or "cholerine" ought to be checked. 

These views have very few advocates besides Thomas Watson, 
of London. Patients have died of cholera without vomiting or 
purging; though, in some, after death, the intestines have been 
found to be distended with the rice water liquid. The checking 
of the discharges is almost always the sign of improvement and 
recovery of the patient. The accumulated evidence, in Europe 
and this country, shows that it is important to check all watery diar- 
rhoeas in cholera times— such fluxes having been proved to be pre- 
monitory of cholera. 

5. Ice to the Spine. — Dr. John Chapman's ice-bags have attracted 
much attention. As ice is so useful when internally given in 
cholera, it may be safe and beneficial when applied to the spine. 
It is one of the experiments to consider, in so desperate' a disease. 
There is very little, if any, evidence, however, in its favor. 

6. Sulphuric Acid. — Dr. Cox, of England, afterward Mr. Buxton 
and Dr. Fuller, and more recently Dr. Jules Worms of Paris, 
have especially recommended dilute sulphuric acid in all stages 
of cholera. Many others especially report well of its action in 
the premonitory diarrhoea. Such an action would comport with the 
view of the organic nature of the poison of cholera ; sulphuric acid 
being so potent a destroyer of everything organic. Some confirm- 
ation of the efficiency of this practice was obtained by Dr. Curtin, 
in the Philadelphia Hospital, in 1866. Dr. Worms' treatment 
(based on the results in 238 cases of cholera, and 150 of cholerine, 



TREATMENT OF CHOLERA. 167 

in 1865) is as follows: For prodromic diarrhoea, he makes a 
"mineral lemonade/' of about half a drachm of concentrated sul- 
phuric acid to a pint or more of sweetened decoction of salep 
(arrowroot would do as well). The patient is to take of this every 
hour a wineglassful, till relieved. 

For confirmed cholera, the patient being kept in complete re- 
pose, there is administered every half hour a glass of a similar 
lemonade, of the strength (about) of a drachm to the pint ; ice 
and wine also being allowed ad libitum. 

7. Opium in large doses. — This practice had once many advocates ; 
now they are few. Prof. Austin Flint, of New York, is one 
of them ; at least morphia is advised by him, in full dose, repeated 
if required. The secondary fever is apt to be more severe and more 
often fatal after treatment of the attack by large doses, either 
of opiates or stimulants. Large quantities of brandy have been 
often used, with no good results. 

8. Treatment by antispasmodics and mild stimulants, in small 
doses at short intervals ; K with ice, and external frictions, etc. Pre- 
monitory diarrhoea is very generally admitted to be present in a 
majority of cases of cholera. In the East Indies, many writers 
of different dates assert such a stage to be an exception instead 
of the rule. But, in India, they have a premonitory or incipient 
stage of another kind ; characterized by great languor or depres- 
sion, with restlessness, and sometimes ringing in the ears, occur- 
ring mostly in the night. In this stage, a mild opiate, with a cup 
of warm tea or a small dose of a diffusible stimulant, as a few 
grains of carbonate of ammonium, or a little weak warm brandy 
and water, will arrest the attack in a great portion of cases other- 
wise to become serious. 

Such symptoms, as well as diarrhoea, should be noticed here, 
during a cholera epidemic; and the same treatment will meet 
either. Rest, warmth, and mild, composing, but gently stimulat- 
ing draughts; paregoric, aromatic spirit of ammonia, tincture 
of ginger, lavender, etc., with a mustard-plaster over the abdomen, 
and a hot mustard foot-bath if coldness of the body increase, or 
vomiting begin ; such are safe, and will be efficient remedies. The 
above may be called the first or prodromic stage. 

The next is called the rice-water stage. When the patient has 
severe spasms, I have witnessed excellent results from frequent 



168 TREATMENT OE CHOLERA. 

drachm doses of turpentine and glycerine, equal parts, once in 
half an hour. For that, the treatment of Prof. Horner is also par- 
ticularly adapted. A recipe, based upon his, is as follows : 

#. Chloroform ; Tinct. Opii.; Camph.; Sp. Ammon. Aromat. aa 
f 3jss; Creosot. gtt. iij ; 01. Cinnamon, gtt. viij ; Sp. Vin. Gall. 

f 3ij. — M. 

A teaspoonful of this in a wineglassful of ice-water ; and give 
of that two teaspoonfuls every five minutes ; followed each time by a 
lump of ice. Iced water, to which common salt and carbonate 
of sodium have been added, may be given, a little at a time, as a 
drink. Also give a tablespoonful of brandy every hour or two ; 
or : #. 01. Cajuput., 01. Juniperi, 01. Anisi, aa 3ss.; Ether, 3ss.; 
Tinct. Cinnam., gii.; Liq. Acid Halleri (one part sulphuric acid to 
three of whisky) 3ss. Dose, ten drops every fifteen minutes in a 
tablespoonful of water. 

Friction of the limbs with brandy and red pepper will be, along 
with large mustard-plasters on the back and pit of the stomach, 
useful to promote reaction ; or, dry frictions are often better, with 
hot, dry applications, as hot bricks, enclosed in flannels, placed 
around the patient, to raise the temperature. 

The third stage is that of absolute collapse ; blue, pulseless, 
shrunken, voiceless. Should a case go on, in spite of the above- 
mentioned treatment, into this state, what else can be done ? All 
now seems to be desperate experimentation. There is room yet for, 
and possibility of obtaining, a final triumph. Even in this ap- 
parent morabund condition, I have resorted to enema of brandy 
or other distilled spirits, 3iv ; tinct. capsicum, 3ss ; warm milk, 
2vj ; grasping the end of the rectum, compelling the retention 
of the injection. The patient may soon revive and can swallow; 
then resume stimulants, dry heat, frictions, etc., with concentrated 
nourishment, each prudently administered, carefully observing the 
effects and progress. Thus I have many times witnessed restora- 
tion and rapid convalescence in cases otherwise hopeless. When 
treating cholera we should never despair until life is extinct. 

Duchaussoy and Vernois assert the non-absorption of medicines 
given by the stomach or bowels during collapse; but Magendie 
proved that absorption does occur, and my experience confirms 
this (in such cases) important truth. These measures prove ser- 
viceable in collapse in other cases than cholera, as well. 



CONSTITUTIONAL DISEASES. 

CHAPTER II. 

DIA THESES. 

RHEUMATISM. 

Several affections are included under the term rheumatism : 1. 
Acute articular rhewnatism or rheumatic fever. 2. "Chronic rheuma- 
tism," affecting the joints and sheaths of the muscles. 3. Syphi- 
litic rheumatism, of the long and flat bones. 4. "Rheumatoid 
arthritis." 5. Myalgia. 6. "Gronorrhceal rheumatism." 

Acute Rheumatism. — Only certain persons and families are liable 
to this affection, upon any exposure. It is characterized by high 
fever, with severe inflammation of several of the larger and smaller 
joints ; which, mostly one after another, become swollen, red, hot, 
tender, and painful. The shoulders, wrists, knees, and ankles are 
most frequently so affected. Although with a full and rapid pulse, 
the skin, after the first week or so of the attack, is often bathed in 
perspiration. The duration of an attack under various methods 
of management have averaged from ten to twenty-one days. 
Sometimes it has been allowed to extend over months ; the sequela;, 
or resulting deformity and crippling of the joints, may remain 
during life. * 

Etiology. — The immediate pathological cause of rheumatic 
fever, is the presence in the blood of a poisonous material, pro- 
duced within the system by some disturbance of the nutritive and 
eliminatory processes. This is generally presumed to be an ingre- 
dient of one of the ordinary excretions, only existing in excess, 
the common belief being that it is lactic acid. The results of ex- 
periments seem to favor this view, the usual phenomena of rheu- 
matism having been produced by injecting this substance into 
serous cavities. 

Predisposing Causes. — Rheumatism is distinctly a hereditary disease. 
It occurs chiefly in persons from fifteen to thirty-five, but especially 
from sixteen to twenty years of age, being rare in children and old 
persons, although no age is exempt. Previous attach decidedly in- 



170 RHEUMATISM. 

crease the predisposition. More cases are met with among males, 
and in the poorer classes, on account of greater exposure to the 
exciting causes. Climate and season have considerable influence, 
the affection occurring mainly in temperate but very moist climates, 
and where there are sudden changes in temperature. It is far less 
common in tropical and very cold countries. A state of ill health 
from any cause may predispose to rheumatic fever, and also mental 
depression or anxiety ; but individuals are attacked when in ap- 
parent perfect health. Joints which are much used, or which have 
been injured, are the most liable to become affected. 

Exciting Causes. — An exciting cause is a sudden chill, produced 
either by exposure to cold and wet ; sitting in a draught when 
heated or perspiring; neglecting to change wet clothes, etc. In 
not a few instances no definite cause can be fixed upon, and it is 
quite conceivable that processes may go on in the system, which 
gradually tend to generate an amount of the poison sufficient to 
produce the complaint. Errors in diet, suppression of menses, and 
other disturbances, have been ranked as causes. Scarlatina seems 
to produce rheumatism sometimes, probably by preventing excre- 
tion. The rheumatic diathesis existing, these and other causes may 
occasion rheumatism. 

Anatomical Characters. — The morbid changes produced by 
rheumatism are chiefly evident in fibrous, fibro-serous, or synovial 
structures. A variable number of the joints are in a state of acute 
inflammation. The synovial membrane is very vascular, thickened, 
and relaxed ; there may be a deposit of more or less lymph, and 
the joint contains some fluid effusion. This is not very abundant, 
chiefly serous, but containing flakes of fibrin and cells, which often 
resemble pus-cells. The tissues around the joint are much infil- 
trated with fluid. In cases which have lasted long, pus may form, 
and the cartilages sometimes become eroded. The sheaths of ten- 
dons may be inflamed, and occasionally contain a purulent fluid. 
The muscles are often dark, soft, and infiltrated. 

Besides the joint affection, there are usually evidences of peri- 
carditis, endocarditis, or nrvocarditis. Fibrinous vegetations are 
common in the heart, even when no inflammation exists. Pleurisy 
and pneumonia are also commonly present, and, rarely, peritonitis, 
or cerebral or spinal meningitis. 



RHEUMATIC FEVER. If 1 

The blood contains excess of fibrin, and becomes buffed and cup- 
ped during coagulation. The solids generally are diminished, but 
are in excess in the serum. Experiments by Richardson, and 
others, proved that an excess of lactic acid can be found in it. 

Symptoms. — An attack of rheumatic fever may be preceded by 
a general state of bad health for some time, and come on gradu- 
ally ; but usually the invasion is marked, there being chills, of oc- 
casionally distinct rigors. These are followed by fever, and soon 
the joints or other structures are affected. 

When the disease is established, the symptoms are usually very 
characteristic. The patient presents an aspect of pain and suffer- 
ing, with restlessness and weariness, but is unable to move on 
account of the pain which is thus produced, and often there is 
complete helplessness. Usually copious perspiration exists, the 
patient being ba*hed in sweat, which has a peculiarly sour or acrid 
smell, and is usually very acid in reaction. Sudamina are not un- 
common, and may be extremely abundant, coming out in succes- 
sive crops. 

The pulse is generally full and strong. The tongue is thickly 
coated, with much thirst, anorexia, and constipation. The urine 
is markedly febrile, deposits urates abundantly, and sometimes 
contains a little albumen. Patients cannot sleep on account of the 
pain they suffer, but there are no particular head symptoms as a 
rule. Occasionally slight delirium exists. 

State of the Joints. — Pain and stiffness are generally complained 
of over the body, but the joints become especially affected. It is 
the middle sized joints which are most commonly attacked, as the 
elbows, wrists, knees, and ankles, but the others are by no means 
exempt. Usually several are involved in succession, the complaint 
showing an erratic tendency, and often the symptoms subside in 
one articulation, as they appear in another, but several may be 
implicated together. A joint may be attacked more than once in 
the course of the disease. A disposition to symmetry is occasionally 
noticed. 

An affected joint is more or less red, either all over or in patches, 
swollen, and hot. The amount of enlargement varies, and it is 
due partly to infiltration of the tissues around the joint, partly to 
effusion into its interior. The skin sometimes pits on pressure. 



172 H&EttMAfIC FEVElt. 

There is considerable pain and tenderness, which is aggravated at 
night ; any movement causes much distress. In character the 
pain is dull and aching as a rule, and it is often so severe as to 
make patients cry. There is less suffering when there exist much 
swelling. But the general symptoms are not always in proportion 
to the extent of the mischief in the joints. 

Temperature. — The ascent usually lasts about a week, but it may 
be longer or shorter. The temperature in most cases ranges from 
100° to 104°. The stationary period varies greatly in duration ; 
there is generally a considerable difference between morning and 
evening temperature. Defervescence is also gradual and indefinite 
in most cases. Rarely crisis occurs. The implicated joints may 
indicate a higher temperature than other parts. It is in cases 
of rheumatic fever that hyperpyrexia is most frequently observed, 
a remarkably sudden increase of heat taking place, accompanied 
with severe symptoms, and death usually speedily ensuing. The 
temperature may reach 108°, 109°, 110°, or more, and continue to 
rise after death. 

Irregularities in temperature are very common in rheumatic 
fever, even without the influence of any complications, and the 
latter are often not indicated by the thermometer in this disease. 
There is often a disproportion between the temperature and the 
pulse. 

A subacute variety of rheumatism is by no means uncommon, 
which is very troublesome. There is very little fever, and one or 
more joints are affected for a long time, the conditions being almost 
stationary, with occasional exacerbations, which are liable to occur 
from slight causes or without any evident cause. The joints are 
not much deformed, nor are they structurally altered to any great 
degree. The general condition is usually much below par, which 
may account for it. 

Complications. — In most cases certain internal organs and 
structures are implicated in the course of a rheumatic attack, and 
the resulting affections are ordinarily classed as complications, but 
in reality most of them are parts of the disease, and they may exist 
without any joint affection. They will be merely enumerated, as 
their symptoms and signs are described in other parts of this work, 
but it must be mentioned that they may come on very insidiously, 



RHEUMATISM. 173 

and should, therefore, be constantly watched for,"especially in the 
case of the heart, this organ being examined at least twice daily. 
They must necessarily influence greatly the course of a case. They 
include : 1. Cardiac affections, viz : pericarditis, endocarditis, with 
consequent valvular disease, myocarditis, and the formation of fi- 
brinous deposits in the heart. 2. Pulmonary affections, viz : pleurisy, 
pneumonia or bronchitis. 3. Rarely peritonitis. 4. Cerebral and 
spinal meningitis, also very rarely. 

The cardiac affections are those observed in the great majority 
of cases ; some think endocarditis, others pericarditis is the more 
frequent. They occur especially in the young, and are met with 
in cases of all grades of severity. In not a few instances both 
the heart and lungs, with their coverings, are inflamed at the same 
time. 

Choreiform movements sometimes complicate acute rheumatism 
or even distinct chorea, especially in children. The relation be- 
tween them is a matter of doubt It is supposed that the chorea 
is due to the plugging of the small vessels of some part of the 
brain with small particles of fibrin from the heart. 

The rapid rise of temperature in some cases is accompanied with 
rigors, violent nervous symptoms, and sometimes jaundice, diar- 
rhoea, hemorrhages, etc. In some instances typhoid symptoms set 
in during the progress of a case of rheumatic fever. 

Duration and Termination. — The duration is exceedingly vari- 
able, but favorable cases generally are convalescent within from 
one to three weeks. Relapses are frequent. The termination, in 
the great majority of cases, is in recovery, but unfortunately this 
is often only partial, some permanent organic mischief being left. 
Sometimes stiffness of joints remains for a considerable period, or 
they may become chronically affected ; they are also liable to sub- 
sequent neuralgic pains. If death results, this is generally due to 
complications. 

Diagnosis. — Gout is the chief disease from which rheumatism 
has to be diagnosed ; the points of difference will be considered 
under gout. Ordinary articular rheumatism has also to be distin- 
guished from other forms. It may be simulated by erysipelas, 
pyaemia, trichinosis, den^He, or the early stage of glanders. It 
must be remembered that rheumatism may occur without any joint 
symptoms. 



174 TREATMENT OP RHETJMATiSM. 

Prognosis. — As regards life and death the prognosis is very 
favorable, but in many instances it is grave with respect to the 
future condition of the patient. Of course this will depend on the 
organic mischief remaining. There are some signs of danger, viz : 
a very high temperature, or one remaining high for some time ; 
severe nervous symptoms ; adynamic symptoms ; extensive compli- 
cations about the heart or lungs ; cerebral or spinal meningitis ; 
deficiency of excreta. Chorea is considered to be a highly danger- 
ous complication, especially when associated with dysphagia. I 
have, however, seen recovery take place when these were present. 

Treatment. — There has been more difference of opinion about 
the treatment of rheumatic fever than of almost any other disease, 
and it is very perplexing for beginners to know what to do, when 
they read the contradictory statements made with regard to this 
matter. Having had opportunities of treating a large number 
of cases, I venture to hope that the remarks here made on the 
subject may not be altogether valueless. 

The indications for managing a case of rheumatic fever seem to 
me to be these : 1. To study the general comfort of the patient, 
and to protect in every possible way from exposure. 2. To use all 
measures to prevent the internal parts from becoming involved. 
3. To encourage free excretion. 4. To remove or neutralize the 
poison in the blood. 5. To attend to the joints. 6. To relieve 
other symptoms. 7. To treat complications as they arise. 

A patient suffering from rheumatic fever should become conva- 
lescent as soon as possible, but it is a matter of much greater con- 
sequence that the attack should be passed through without any 
permanent organic mischief being left behind, especially in con- 
nection with the heart, than that recovery should take place within 
this or that number of days or weeks. 

There are certain matters connected with general management, 
of the greatest importance. The patient should be placed in a 
comfortable bed, between soft blankets, and wear a flannel shirt, the 
limbs being fixed in as comfortable a position as possible, by means 
of pillows. It is necessary to avoid anything like a chill, hence 
the bed should be carefully protected from all draughts, and pa- 
tients should not be allowed to throw off the bedclothes, which 
they are much inclined to do. Wrap up all the joints, whether 



TREATMENT OF RHEUMATISM. 175 

affected or not, in cotton, or wool, which is better; and also to put 
a thick layer of this over the front of the chest. It is further advisable 
to cut the shirt in such a way as to make a kind of window over 
the region of the heart, by drawing aside which this region may be 
examined without disturbing the patient, or exposing much of the 
chest. The wool must be frequently changed, the surface being 
dried before each fresh application is made. 

The diet ought not to be too low, but should consist of a good 
quantity of beef-tea and milk, regularly administered. Much 
drink is needed, and the best is lemonade or barley-water. Ice is 
also very agreeable to the patient. Alcoholic stimulants are not re- 
quired in ordinary practice as a rule ; still, patients may need 
them, and sometimes in considerable quantity, if accustomed to 
them. If there is a tendency to much debility and prostration, 
then they should be given, as required. 

It is necessary to keep the bowels regularly open, but the treat- 
ment of acute rheumatism by the use of strong purgatives, as 
practiced by some, is very improper, as tending to invite the 
disease to the bowels. 

General Therapeutic Treatment. — Observations have been made 
with the view of proving that rheumatic fever runs as favorable a 
course without as with medicines. Possibly this may be true, 
if the conditions already mentioned are carefully attended to. At 
the same time my own experience would lead me to attribute good 
results to the alkaline treatment, as I have seen unmistakable ben- 
efit speedily from it. It certainly appears to have an influence 
over the joint-affection, and I am inclined to think it tends to pre- 
vent the heart structures from becoming involved. At the Liver- 
pool Northern Hospital, where a large number of these cases were 
admitted, this was the treatment adopted, and heart complications 
occurred very exceptionally, provided they were not present at the 
time of admission. The bicarbonate of potash, or bicarbonate of soda, 
are what I usually employ, either given in doses of 3i to 9ij every 
three or four hours, or 3i or more being dissolved in a quart of 
barley-water, and consumed during the twenty-four hours. At 
the same time give enema of same with 3ss of fl. ext. Hyoscyamus 
in each, to relieve pain and procure sleep. Much larger doses are 
recommended by some practitioners, and others prefer the salts 



176 RHEUMATISM. 

with the vegetable acids, such as the citrate or tartrate, and these 
may be made into a pleasant drink. I have had excellent results 
from the use of ammonia in rheumatism. 

It is proper to mention some of the numerous plans of treat- 
ment which have been employed in this disease, some of which 
merit a more extended trial than they have yet received. 

Calomel, venesection, and tartar-emetic are entirely out of use, 
and no one would think of recommending them at the present day. 
Some prefer the salts of soda to those of potash. Nitrate of potash 
has been much used, in quantities of from 3ss. to 3i in twenty- 
four hours. Iodide of potassium, phosphate of ammonia, benzoates, 
and various other salts have also been tried. Lemon-juice has its 
supporters, from 3iij to 3xij or more, being given in the twenty- 
four hours. Having used it in many cases, it did not give satisfac- 
tory results. Some recommend quinine or cinchona bark in full 
doses; the former may be conveniently combined with alkalies. 
Recently tincture of steel has been extensively tried, and the results 
are not altogether satisfactory. Potassio-tartrate of iron has been 
well spoken of. Sulphur and guaiacum have also been recommend- 
ed, but they seem more useful in the chronic variety. Many use 
colchicum, but it is valuable only in certain conditions. 

Remedies which act powerfully upon the heart have been em- 
ployed, viz : aconite, digitalis, and veratrum viride, especially the 
latter. . They may have the effect of diminishing the tendency to 
cardiac inflammations, but require careful watching. Some treat 
acute rheumatism by blistering each joint as it becomes affected, 
the blisters encircling the limbs, this being followed by the appli- 
cation of emollient poultices. Various baths have been tried, 
especially the hot-air bath. 

Salicylic acid has recently received considerable notice as a 
remedy^for rheumatism, and occasionally giving favorable results 
in certain cases and conditions ; but on the whole no very general 
or decided testimony has been given as to its reliability£in this 
disease. 

Local Treatment. — Ordinarily it is proper to apply cotton or wool 
to the joints. In some instances the pain is so great that local 
applications must be made. As a rule warm alkaline and anodyne 
fomentations or poultices give most relief, containing opium, bella- 



CHRONIC ARTICULAR RHEUMATISM. 177 

donna, or their active principles, or atropine. To be of much 
benefit they must be put on very hot, well covered and frequently 
changed. Various anodyne liniments, as Comp., chloroform lini- 
ment, etc., or a solution of chloral, are proper applications, often 
proving beneficial. Free blistering with liquor epispasticus cer- 
tainly not unfrequently gives speedy relief. It is not uncommon 
for a joint to show a tendency to become chronically affected after 
the general symptoms have subsided. If this happens, application 
of tincture of iodine and fomentations should be first tried, but 
if a speedy effect is not produced it is best to strap the articulation 
carefully with plaster of ammoniacum. If there is much effusion, 
tapping the joint by means of an aspirator may become necessary. 

If hyperpyrexia comes on in acute rheumatism, the use of cold, 
as described under fever, with quinine in full doses internally, and 
large quantities of stimulants, are proper. Cases successfully treat- 
ed in this manner prove that patients may be saved when in an 
apparently hopeless condition. 

Fomentations externally, and opiates internally, are the chief 
remedies, followed by blisters, if there is pericardial effusion. 
Opiates must be used with caution, if the lungs are involved, and 
free stimulation is necessary. Cerebral or spinal meningitis must 
be treated as directed in that disease. 

Great care is needed during canvalescence, flannel being worn, 
and all exposure avoided. The diet should be improved gradually. 
The patient should have full instructions as to how to guard 
against future attacks. 

Chronic Articular Rheumatism. 

Symptoms. — This disease is quite common among old people, 
usually coming on gradually as age advances, but occasionally fol- 
lowing an acute attack. The fibrous structures connected with 
and around the articulations become thickened and stiff, move- 
ment is impaired, and there is more or less dull, aching pain, worse 
at night and during damp or cold weather. There are no particu- 
lar objective signs, the joints being not much altered in form. 
This condition may be associated with chronic changes in the 
valves of the heart. 

Treatment. — Wear flannel next the skin, avoid exposure or 
changes of temperature. Various kinds of baths are useful in 



178 MUSCULAR AND TENDINOUS RHEUMATISM. 

different cases, as warm, vapor, hot-air, Turkish, cold, salt-water, 
sulphur, or alkaline baths. These may also be employed locally. 
Systematic daily friction of the affected parts often does much good, 
with some stimulating and anodyne liniment, such as comp. chlo- 
roform ; or camphor liniment, with laudanum, tincture of aconite or 
belladonna ; also, shampooing and kneading. Local counter-irri- 
tation or tincture of iodine, sometimes is beneficial. Carefully 
strapping an affected joint with some plaster, is proper, as emp. 
ammoniaci, red plaster, etc. It is well to keep the joints band- 
aged. Direct a moderate amount of exercise. Electricity in the 
form of the constant current sometimes proves very efficacious. 

The best internal remedies are tonics. Quinine and cod-liver 
oil, or tincture of iron ; Iodide of potassium with decoction of bark 
is also useful. Sulphur, guaiacum, sarsaparilla, and many other 
things, have been recommended as specifics. It is often requisite 
to give some anodyne to relieve pain, and procure rest at night. 
Various mineral waters may sometimes prove serviceable. Proper 
digestible and nutritious diet is indispensible. Slight stimulation 
may be occasionally needed. 

Muscular and Tendinous Rheumatism— Myalgia. 

The muscles may become the seat of a very painful affliction, 
which is supposed to be rheumatic, probably involving the fibrous 
structures. 

Cause. — Either exposure to cold and wet, or to a direct draught, 
or excessive exercise of the muscles. This malady is most fre- 
quent in adults, and some forms of it are most common among 
laboring men. One attack prodisposes to another, and gout seems 
to increase the tendency to. the disease. 

Symptoms. — Usually the first attack is acute, and it often begins 
during the night, with pain in the affected muscles and some ten- 
derness, with considerable stiffness, and difficulty of movement, 
which occasions much pain. The degree of suffering varies, it 
may be intensely severe ; it may only be felt on moving the affect- 
ed muscles, likewise when they are at rest, being sometimes asso- 
ciated with spasm. In acute cases heat increases the pain, and it 
is also worse at night, so that patients suffer more when in bed. 
Steady pressure in some cases gives relief. There are no objective 



RHEUMATISM. 179 

signs, except that it is evident the patient keeps the involved 
muscles as much atYestTas possible. There is no fever, or very 
slight, occasioned by the pain and want of sleep. No tendency to 
cardiac affections. 

In the acute form it usually lasts but a few days, but it often be- 
comes chronic, or is liable to return. When it is chronic, heat 
generally relieves, and cold and damp weather increases the pain. 

Varieties. — 1. Cephalodynia, or rheumatism of the scalp, attend- 
ed with a form of headache, increased on moving the muscles, with 
much soreness on pressure. 

2. Torticollis, wry-neck, or stiff-neck. — This is a very common variety, 
involving the muscles of the neck, especially the sternomastoid. 
Usually it is limited to one side, towards which the neck is immov- 
ably twisted, great pain being experienced on attempting to turn. 
The muscles of the back of the neck may be implicated. 

3. Omodynia, Scapidodynia, Dorsodynia. — These are very commonly 
observed, especially among laboring men, the muscles about the 
shoulders and upper part of the back being affected. 

4. Pleurodynia, or Rheumatism of the Chest-walls. — The muscles 
of the chest are implicated, usually those of the left side. The 
intercostals, pectorals, or serratus magnus may 'be involved, the 
pain is frequently seated over the interdigitations of the serratus 
with the external oblique. It is often situated in the left infra- 
axillary region. It may be intense, and is increased by any move- 
ment of the muscles. Respiration is imperfect on the affected side. 
Coughing or sneezing are very distressing. Often the chief pain 
is localized, and 'of a catching character, pressure on this point in- 
creases it, though diffused pressure with the palm may give relief. 
In other instances it alters its position. This simulates pleurisy, 
but is distinguished from it by the absence of physical signs. It 
often comes on as'the result of cough, and both sides may be then 
affected. Phthisical patients commonly suffer from it. 

5. Rheumatism of the Abdominal-walls is exceedingly painful, and 
may^be^mistaken for peritonitis. ItTrequentlyJresults from strain- 
ing during cough. 

6. Lumbago. — The muscles and fasciae in the lumbar region are 
common seats of this complaint. It may begin with peculiar rapid- 
ity, and is usually severe. Generally both sides are affected. 

15* 



180 TREATMENT OF RHEUMATISM. 

There may be constant aching pain ; it is increased on any attempt 
to bring the muscles into action, and of a sharp, stabbing char- 
acter. The patient keeps the spine stiff, and a little bent forward ; 
any effort to stand erect, or to get up, aggravates the sufferring. 
Sometimes the patient cannot rise from bed. Pressure causes 
much pain, and so does heat often. 

In addition to these varieties, muscular pains are common in the 
limbs. Sometimes cases are met with appearing as if the plantar 
fascia and muscles were involved. The diaphragm is occasionally 
the seat of rheumatism, causing great distress. The fibrous and 
muscular structures of the eye are subject to rheumatic inflamma- 
tion. The sheaths of nerves also suffer, and are very painful neu- 
ralgic maladies. 

Treatment. — The affected muscles must have rest, and in some 
cases this is all that is required. Treat pleurodynia by firmly strap- 
ping the affected side with broad strips of plaster, extending from 
mid-spine to mid-sternum. Tnis rarely fails to give complete 
relief. In lumbago also, the application of a wide piece of emp. 
roborans across the back, and over this a flannel bandage, passing 
twice round the body, always gives great comfort. In acute cases 
warm fomentations, containing some anodyne, are useful, or tur- 
pentine fomentations. Dry heat generally increases the pain, but 
sometimes, if persevered in, it does good. Gentle friction is often 
beneficial. In lumbago the subcutaneous injection of a little 
morphia generally affords very considerable relief, and patients ask 
to have it repeated. Internally the administration of bicarbonate 
of potash, or soda, or iodide of potassium, seems to answer best. 
Chloral, hyoscyamus, or other anodyne, may be necessary to relieve 
pain. Exciting free diaphoresis by warm drink, while wrapping 
up in blankets, or the use of a vapor-bath, sometimes produces a 
rapid cure. 

In chronic cases the internal remedies which are most effective, 
are iodide of potassium, quinine, or chloride of ammonium. Sul- 
phur, guaiacum, arsenic, mezereon, and various balsams and resins, 
have been recommended; also colchicum, if there is any gouty 
tendency. Flannel should be worn next the skin. Rest, pressure, 
friction, with stimulating and anodyne liniments, sinapisms, blis- 
ters, and local baths or douches, with shampooing, constitute the 



GONORRHEAL RHEUMATISM. 181 

usual local measures employed. Galvanism is sometimes attended 
with success. It may be advisable to use subcutaneous anodyne 
injections daily, for a few days in succession, early in a case. 

Gonorrheal Rheumatism. 

Symptoms. — During the course of gonorrhoea, especially in 
young and plethoric persons, an affection of the joints may occur, 
as the result of exposure, the knee-joint being that most commonly 
attacked. The ankles, feet, or hip-joints are also not unfrequently 
implicated. There is considerable pain, with swelling, and a ten- 
dency to much effusion and exudation, which occasions great ten- 
sion without suppuration. The inflammation is liable to recur, and 
cause permanent changes in the joint, which may remain stiff for 
a long time, with a crackling sensation on movement, or destruc- 
tion of the cartilages, and anchylosis may result. This may be- 
come chronic. It is accompanied by much constitutional dis- 
turbance. 

Treatment. — The affected joints must be kept at rest, and well 
fomented. When the knee-joint is implicated, the limb should be 
extended on a splint, as it is apt to become bent. In the acute 
stage anodynes may be given, in addition to the ordinary 
remedies for gonnorrhoea. Afterwards iodide of potassium is use- 
ful, with tonics and stimulants, if the patient is weak. Friction, 
shampooing, and movement of the joint, must be carefully prac- 
ticed when the case becomes chronic. Strapping it may be useful. 

Syphilitic Rheumatism. — As stated already, this affects the long 
and flat bones chiefly, and mostly between the joints, not at them. 
Generally there is nodosity upon the bones affected, or some degree 
of periosteal inflammation, at least. 

The remedy for syphilitic rheumatism is iodide of potassium. It 
will usually relieve the pains in a few days. They may return in 
the course of months or weeks, when the same treatment should 
be renewed. Ten to twenty grains of the iodide potash, thrice 
daily, will suffice. 

Rheumatoid Arthritis — Arthritis Deformans. 

Etiology. — This is a curious form of joint inflammation, which 
results in great deformity. It occurs in the debilitated, and whose 
circulation is languid. Most cases are met with between twenty 



182 RHEUMATOID ARTHRITIS — ARTHRITIS DEFORMANS. 

and forty years of age, and among females. The complaint almost 
always is observed among the poor, and of bad habits. It may be 
traced to cold or damp, sometimes to injury, but there may be no 
obvious cause. It is doubtful whether it is at all hereditary. 

Anatomical Characters. — At first there is redness and increase 
of synovia. After a time the capsular ligament is greatly thick- 
ened, with irregular proliferations, and the synovial fluid becomes 
much diminished. The internal ligaments may be destroyed, tend- 
ing to dislocations. Within the articulation are fibrous bands, and 
there may be cartilaginous or bony masses. The interarticular 
fibro-cartilages break down and disappear, as do the cartilages cov- 
ering the ends of the bones. The ends of the bones become smooth 
and eburnated to a greater or less extent, being also enlarged, 
sometimes considerably, and either regular, or. more commonly, 
very irregular, owing to osseous protuberances. There is no deposit 
of urates. 

Symptoms. — This affection may be acute or chronic. In the former 
case several joints are involved, but there is no erratic tendency, such 
as is observed in ordinary rheumatic fever. Pyrexia is present, 
but not profuse sweating, nor does the heart become implicated. In the 
chronic variety one joint is first affected with a little pain and 
swelling, but it recovers ; in a short time it is again attacked, and 
remains permanently altered, becoming worse. Other joins then 
are involved in succession, until all those of the limbs may be 
observed in various stages of alteration, and also the temporo- 
maxillary and upper cervical articulations. As a result the joints 
become rigid, motionless, and either permanently bent or extend- 
ed ; there is more or less distortion with nodulation, contraction, 
and wasting of the muscles, the patient being finally completely 
crippled. At first there may be signs of fluid in a joint. In some 
cases dislocation takes place. The pain may be very considerable, 
especially at night. There are no particular constitutional symp- 
toms. The hands are usually crippled before the feet. On the 
former also little nodular thickenings of the epiphyses of the pha- 
langes, "digitorum nodi," are sometimes seen in connection with 
the terminal phalanges, supposed to be rheumatoid arthritis, but 
some believe them to be gouty. Other parts are sometimes in- 
volved in this disease, as the sclerotic, internal ear, or the larynx. 



GOUT — PODAGRA. 183 

Diagnosis. — This disease must be distinguished from gout, ordi- 
nary rheumatism, acute or chronic, and gonorrhoeal rheumatism. 
The structural changes and deformity distinguish it from ordinary 
chronic rheumatism and gonorrhoeal, the latter having a different 
history. 

Prognosis. — Acute cases, if properly treated, may do well. If 
the disease is chronic and advanced some improvement may be 
made, but not much as a rule. 

Treatment. — The system is always in a low state, and needs a 
sustaining treatment} which must be persevered in. The general 
health requires special attention ; the diet must be nutritious and 
easily assimilated; wine, or some other form of stimulant is re- 
quired. Warm clothing, an equable climate, pleasant occupation, 
and moderate exercise, with baths, are proper. 

Iron and quinine, with cod-liver oil, are best internal remedies. 
Syrup of iodide of iron, iodide of potassium, guaiacum, and vari- 
ous other remedies, have been favorably mentioned. Strychnine 
or nux vomica may be tried if the muscles have wasted. Mineral 
waters are sometimes beneficial. , 

Early in cases local counter-irritation is decidedly useful, but 
this does not produce much effect after a time. Free bathing with 
salt and water, followed by friction, seems to do most good ; sys- 
tematic strapping of the joints, friction with various liniments, 
shampooing, and careful movement, are beneficial. 

[ Hartshorne's Conspectus and Roberts' Practice afford the material for 
much of this and the previous chapter, modified to meet the editor's views in 
compiling them.] 



00 UT-PODAGRA. 

Etiology. — Gout is hereditary, as manifest in its occurrence. It 
is rare before puberty, or even under thirty, except in hereditary 
cases ; most first attacks occur from thirty to thirty-five, and it 
does not often begin late in life. Males suffer more than females. 
Those of a sanguine temperament, plethoric, and corpulent, are 



184 GOUT — PODAGRA . 

most subject ; but thin, nervous, wiry persons are liable to it. In- 
dividuals who work in lead are prone to be gouty; and gouty peo- 
ple readily suffer from lead-poisoning. Cold and temperate cli- 
mates are worst, especially those damp and changeable. 

Indulgence is most conducive to the development of gout, as in 
alcoholic drinks, excessive food, especially animal food, and deficient exer- 
cise, with general luxurious habits. It is a disease more prevalent 
among the opulent. There is a form of "poor gout," due to drink- 
ing much beer, and living badly. A hereditary tendency exists in 
some of these cases. Previous dyspepsia, etc., favor its occurrence. 

The immediate pathological cause of gout is generally believed to be 
the excess of uric acid in the form of urate of soda in the blood, this 
being produced in excess because of the habits above mentioned, 
and the kidneys being unable to excrete this excess. During an 
acute attack, uric acid may be detected in abundance in the blood- 
serum ; in chronic cases, it may be obtained from this fluid at any 
time. It is also found in the fluid of blisters or serous inflamma- 
tions, and in dropsical accumulations. 

Exciting Causes of Gout. — An attack of gout may have no evident 
cause, or is brought on by exposure to cold or wet; slight injury; 
excessive exertion and fatigue ; mental labor ; violent or depress- 
ing emotions, such as rage or grief; over-eating or drinking, and 
indulgence in indigestible food, etc. 

Anatomical Characters. — Gout is a deposit of urate of soda 
from the blood in various structures, especially those forming the 
joints, and those not very vascular. In an acute case there is in- 
creased vascularity and swelling of tissues, and effusion in and 
around the joint. Early only the joint of the great toe is usually 
affected, subsequently other articulations are involved, until almost 
all may be implicated. The deposit first occurs in the superficial 
part of the cartilages, in the form of fine crystalline needles or 
prisms, forming a close network, and presenting different degrees 
of opacity. Subsequently the fibro-cartilages, ligaments, and 
synovial membranes are affected, the entire surface being more or 
less irregular, and covered with white, chalky-looking deposits, 
consisting of urate of soda. The synovial fluid may contain crys- 
tals of the same. Owing to the infiltration of the ligaments, the 
articulations become stiffened or anchylosed. In long-continued 



GOUT — PODAGKA. 185 

cases, the joints become distorted ; the skin may be destroyed, ex- 
posing the chalky-looking masses. The periosteum and mucous 
bursae may be affected, and possibly the bone. Deposits are found 
in ear, nose, eyelids, and larynx. 

The kidneys change at an early period. At first a deposit of urate 
occurs within the tubuli, and this extends into the intertubular 
tissue. White streaks are seen in the direction of the tubuli 
of the pyramid?, and at the extremities of the papillae. Ultimate- 
ly the organs become greatly contracted and indurated, as well as 
the*seat of extensive deposit. 

Symptoms. — An acute attack usually, heartburn, flatulence, dull 
pain in left side of chest, irregularity of action of the heart, skin 
dry, urticaria, and urine loaded with urates. Often in the night 
begins suddenly, with acute pain in the great toe, instep, or heel ; 
a chill succeeded by heat, tenderness and swelling in the affected 
part ; fever, irritability, and restlessness ; with furred tongue and 
constipation ; urine containing abumen, and loaded with urates 
and phosphates. The attack subsides ; an interval elapses propor- 
tionate to the care taken ; then follows another attack, and so on 
in persons subject to it. In chronic gout, tophi or chalk-stones 
form around the joints, on auricle of the ear, etc., chiefly consist- 
ing of urate of soda. 

Complications. — Metastasis occurs from the joint to some internal 
organ, as the stomach, heart, membranes of the brain. This may 
be caused by the application of cold to a limb affected. There may 
be a gouty diathesis without local manifestations, causing neu- 
ralgia, d}^spepsia, palpitation, syncope, urticaria, piles, toothache, 
or pains about the head, tonsillitis, etc. The diathesis or chronic 
form of gout is a common cause of disease of the kidneys, arteries, 
heart, and indirectly of apoplexy. 

The duration of an attack varies from four or five days to weeks, 
in the latter there are intermissions or remissions. These increase 
as the disease advances. Recurrence is common, though not invari- 
able. At first, the attack may occur once a year, in the spring ; 
then twice, spring and autumn ; more frequently, and at any 
season afterwards. 

Diagnosis. — Between gout and rheumatism there is greatTCsem- 



186 TREATMENT OF GOUT. 

blance ; and they may be blended together. When clearly exem- 
plified, the following differences may exist : 

The small joints are chiefly affected in gont; in rheumatism, the 
larger joints. Repetition of attacks is much more frequent in 
gout ; their duration is greater in rheumatism. In gout, the heart 
is seldom attacked, and spasmodically ; in rheumatism, the heart is 
often subject to inflammation. In gout, the stomach is sometimes 
spasmodically affected, with violent symptoms; in rheumatism, 
almost never, although the bowels may be. In gout, uric acid (or 
urate of sodium) is in excess in the blood. In pure gout, colchi- 
cum generally does good ; in pure rheumatism, hardly ever. 

Treatment. — The indications are to eliminate the excess of blood 
poison, as the urates, phosphates, etc., and regulate the general 
derangements. 

An emetic of ipecac may be required to unload the stomach 
of crude ingesta, followed by a brisk cathartic to clear the bowels 
of accumulations; after which colchicum and alkalies* are the 
remedies to relieve gout. Most patients will bear doses of fifteen to 
twenty drops of wine of colchicum seed or root for a few days ; 
then it must be discontinued when relief comes, for a time, as it is 
apt to irritate the stomach and bowels ; or, carbonate of potassium, 
or sodium, ten to thirty grains, with drachm doses of Rochelle 
salt, are important additional remedies, given two or three times 
in twenty-four hours. Anodynes may be required to relieve ex- 
treme pain. 

Local Remedies.— Cold must not be applied, for fear of repulsion 
of the gout to the stomach, brain or heart. Warm anodyne, alka- 
line fomentations are excellent applications. This may be pre- 
ceded by warm anodyne discutient liniment, and repeated before 
renewing fomentations. Warm laudanum, or a solution of chloral, 
may be applied by wetting soft linen or muslin with either, and 
covering these with oiled silk. 

Gout affecting the stomach or heart spasmodically is usually sud- 
den, violent, and prostrating, requiring prompt stimulation, with 
brandy, Hoffman's anodyne, chloroform, or neutralizing cordial. 
Small or moderate doses of one or another of these should be given 
at short intervals. Mustard plasters to the epigastrium, or chest 
and back, and bathe the feet in hot alkaline mustard water to aid 



SCORBUTUS-SCURVY. 187 

reaction. It is important to promote and keep up free action 
of the skin, and equalize the circulation. 

The intervals between the attacks are important. In the early 
stage a practical cure may be effected in acquired cases. Due at- 
tention to certain rules is requisite to this end, and also to benefit 
as far as possible hereditary gout. All pernicious habits must be 
corrected, and great care be exercised to avoid excesses and irreg- 
ularities of every kind. 

The diet must necessarily vary in different cases, and be adapted 
to each ; digestible and nutritious ; of due proportion of animal 
and vegetable food, eating sparingly of saccharine and nitrogenized 
substances. Moderate and regular meals are important, and to 
observe temperate habits. When a change is made in food or 
drink, it should be gradual, not abrupt. 

Hygienic measures, as daily open air exercise in ratio to strength, 
avoiding sedentary habits ; practice bathing, followed by friction, 
to promote free action of the skin ; wear warm clothing, and flan- 
nel next to the shin; avoiding late night hours, and excessive physi- 
cal or mental labor, heated or ill-ventilated rooms, sudden atmos- • 
pheric changes, exposure to wet, currents of air, and everything 
which might predispose to, or induce an attack of gout. 

SCORBUTUS-SCURVY. 

This peculiar and distinct disease was early and generally known 
as "Land and Sea Scurvy" because of its destructiveness of ex- 
plorers of barren regions, of large armies, navies, and voyagers. It 
is a complex morbid condition of the system, caused by long- 
continued privation of fresh succulent vegetables or fruits, or their 
preserved juices. Captain Cook proved the preventive value of a 
due amount of vegetable food. The scorbutic diathesis modifies other 
diseases, and very seriously increases their mortality. 

Symptoms. — The countenance and skin has a sallow, dusky hue. 
The gums are pale, swollen, spongy, livid, and sloughing. The 
breath fetid ; general debility ; hemelopia, deafness, dyspnoea ; 
loosening of the teeth ; hemorrhage from the gums, mouth, nose, 
stomach, and the intestines. Extensive echymosis, brawny swell- 
ing in the hams, and stiffness of the legs ; great lassitude and want 
of energy ; despondency, diarrhaea, dysentery, dropsy, with ex- 
haustion and thrombosis, with general emaciation. This malady. 



188 CONSTITUTIONAL SYPHILIS. 

when severe, presents a vivid example of general physical ten- 
dency to dissolution. This disease comes on insiduously, gradually, 
and is met with in all degrees of severity. 

Diagnosis. — It cannot be confounded with any other disease 
.except purpuria. The history of the case, showing the cause to 
be a want of vegetable food, which is not the cause of purpuria, nor 
can the latter be cured or benefitted b} 7 vegetable diet. 

Treatment. — Pure air, rest in the recumbent posture ; plenty 
of fresh, soft succulent vegetable diet, as potatoes, cabbage, oranges, 
and other fruits, and allow the patient to drink freely of lemonade. 
Beef-tea, milk, cream, and other liquid food, until the mouth and 
gums heal, so that the patient can chew ; then fresh meat and fish 
in considerable amount. Stimulants in moderation may be re- 
quired in the low form for a time, until recuperation is advanced. 
Tonics, as tincture of hydrastias canadensis, or hydrastin, and 
iron, to give appetite and improve the blood. 

Some dilute antiseptic mouth-wash must be used, as Condy's 
Fluid, until fetor ceases, followed with a mild astringent, as alum 
water, or tannic acid and tincture of myrrh. Constipation should 
be relieved by enemata. The painful swellings in the legs require 
anodyne fomentation. Hemorrhages must be treated with astrin- 
gents. Any ulcers occurring generally improve rapidly by the 
proper diet, but must be daily cleansed, and may be treated with 
lime-juice, and protected with cerate or other simple dressing. 

The prevention of scurvy by the use of such food already indi- 
cated, is an important duty incumbent upon medical men who have 
charge of soldiers, voyagers, explorers, and those about to enter 
upon such duties and enterprises. Hygienic, and other measures 
for securing and maintaining the general health of those under 
their care, are imperious professional and humane duties. 

Constitutional Syphilis. 

Secondary syphilis may appear after weeks or months contin- 
uance of the primary disease, often greatly impairing the consti- 
tution life-long, and transmitting the taint to offspring. 

Constitutional syphilis results from an indurated or infecting chan- 
cre, causing chronic ill-health ; often producing obscure diseases 
of the vital organs, affections of the bones, obstinate ulcers of the 



TREATMENT OF CONSTITUTIONAL SYPHILIS. 189 

skin and mucous membranes, loathsome skin diseases, impotence 
or sterility, death of the foetus in utero, or abortion. 

Symptoms. — These are of two kinds, secondary and tertiary, differ- 
ing in character. The secondary symptoms are first general con- 
stitutional disturbance ; fever, mental torpor, lassitude, pains in 
the limbs, and the skin shows a sallow hue. Soon a fugitive roseo- 
lar eruption appears on the chest and abdomen without itching, 
which, when redness is removed by pressure, leaves a yellow dis- 
coloration ; there is usually an attending erythematous sore throat 
and enlargement of posterior cervical glands, and loss of hair. 
Later, secondary skin eruptions may be papular or scaly, of cop- 
pery hue, occasionally pustular, ulcerative sore throat. Patches 
or mucous tubercles appear on the fauces, angles of the lips, about 
the vulva, scrotum, anus, etc., at this stage ; also alopecia, loss 
of eyebrows and lashes ; deafness, iritis, crumbling and discolora- 
tion of the nails, or inflammation and ulceration about their roots, 
and superficial ulceration about the lips and tongue. 

The tertiary disorders of the skin are gummy deposits, rupia, and 
ulcerations ; other tertiary signs are perforating ulcers of the soft 
palate, and destructive ulceration of the larynx, gummatous tumors 
and ulceration of the tongue and of the middle sternum ; and, 
sometimes diseases of the brain, spinal cord, kidneys, liver, heart, 
etc. 

Treatment. — The nourishing and cleansing treatment, in my ex- 
perience, has given favorable and satisfactory results. The diet 
must be nutritious, digestible and readily assimulated, as meat, 
fish, milk, cream, raw eggs, etc.; light wines and water. Daily 
warm alkaline baths, at a temperature of 105° to 120° Fah., fol- 
lowed with proper frictions ; or an alkaline vapor bath on each 
alternate day. Warm clothing, soft flannel or silk worn next to 
the skin, and the avoidance of cold and damp, or sudden atmos- 
pheric changes. Pure air and proper exercise, as able, for invig- 
oration. Avoid fatigue. 

Internally the iodide of potassium, from ten to twenty grains or 
more, three times a day, alone, or combined with other remedies, 
as indicated in the various phases or modifications of individual 
cases. Ulcers should receive due attention, by careful cleansing 
and simple soothing applications. These will granulate and grad- 



190 SYPHlLIZATtON. 

ually heal if the treatment already indicated is thoroughly carried 
out. Tonics, as iron, cod-liver oil, etc., may be indicated in some 
cases. Hot alkaline foot bath while the patient drinks some warm 
diaphoretic tea, before retiring at night, inducing a free perspira- 
tion, give excellent results. A pretty free daily use of mueill- 
agginous diluent drinks greatly assists the natural eneunctories in 
eliminating the syphillitic poison from the system, as all experi- 
ence proves. 

Syphilization — A term applied by Auzias Turenne to the con- 
dition produced by successive inoculations with syphilitic poison ; 
in which each succeeding chancre becomes less and less, until a 
time arrives when no ulcer can be produced by insertion of vene- 
real virus. Hence the inference has been drawn that, by repeated 
inoculation, a constitutional state is induced in which the system 
is no longer capable of being affected by syphilis. 

Sperino inoculates with matter from a soft chancre for from 6 to 
10 chancres at each sitting ; and allows three or four days to elapse 
between each operation. By continued inoculation from the chan- 
cres thus produced the ulcers become less and less until no effect 
is produced ; but the individual is still susceptible, though in a less 
degree, to matter taken from another source, again to a third, and 
so on until at last no effect is produced by any syphilitic poison. 
The general health, instead of suffering, improves during process 
of inoculation. Time required to produce immunity varies; in 
one case it was obtained after seventy-one chancres ; in most in- 
stances upwards of three hundred were produced, treatment last- 
ing for nine or twelve or twenty months, and more. It may be 
practiced at any age. To obtain a complete cure when patient has 
previously been mercurialized, the use of iodine has often to be 
combined with syphilization. Dr. Boeck asserted in 1858, that in 
no disease has the practitioner a more certain method of cure, but in- 
dependent investigation does not bear out this statement. Disad- 
vantages of the method — its offensive nature, and the length 
of time necessary for effectually carrying it out : on the other hand, 
the immunity produced is thought to last for life. 

Infantile Syphilis. — May be hereditary, constitutional, or ac- 
quired. Infants usually born healthy-looking ; but sometimes with 



SCROFULOSIS — SCROFULA. 191 

its skin of a dull color, and its features contracted — like a little 
old man or woman. 

Symptoms. — Generally within the month, symptoms of coryza 
set in ; cough, difficulty in sucking, dryness of the lips and mouth, 
the "snuffles." Voice shrill and hoarse. Superficial ulcerations 
about mouth and throat. Parts around the mouth, nostrils, but- 
tocks, arms, and flexures of joints become copper- colored, fissured, 
and excoriated. Child wastes and gets very weak. Amyloid 
disease of liver. Indurated nodules in lungs. Syphilitic iritis ; 
chronic interstitial keratitis ; deafness. In children with inherited 
syphilis : — A peculiar physiognomy ; tendency to chronic intes- 
tinal keratitis ; notching of central upper incisors of permanent 
teeth (Hutchinson). 

Infantile syphilis usually developes eruptions when the child is 
a month or six weeks old, but may be delayed several months. 
The child has the general symptoms of hereditary syphilis, and 
additional mucous tubercles, and condylomata ; and erythematous 
rashes, which may, or not, become tubercular, on the palms and 
soles, especially on the buttocks, occasionally bulla and pustules 
attend, and are accompanied with deep ulceration. Papular, pus- 
tular, and gummatous eruptions may appear on children as the 
result of hereditary syphilis. 

Treatment. — This must be the same as for constitutional syph- 
ilis. Iodide of potassium, alternated with tonics, early in cases, 
and potassium combined with iron in later stages. Good tonics, 
nourishment, pure air, and cleanliness, will often dispel the erup- 
tions, or at least greatly aid other alterative syphilitic remedies. 
Ulcers usually heal when treated with iodide of starch paste, it 
cleansing them and promoting the granulating process. It is bet- 
ter that such children have the benefit of a healthy wet-nurse, 
which is sometimes indispensible ; or feed with cracker-water and 
cream, alternated with good cows' milk. 

SCROFULOSIS—SCROFULA. 

SYNONYM. — Scrophula; Tubes Glanduralis; Struma; King's Evil. 

There is no subject about which it is more difficult to give a con- 
cise account at the present time than that of the so-called tuber- 
cular affections, there being such different views as to their pathol- 



192 SCROFULOSIS — SCROFULA. 

ogy, and, indeed, even as to what is meant by tubercle; while many 
believe in the identity of the scrofulous and tubercular diseases, 
others consider them entirely distinct. 

Prof. Aitken defines scrofulosis and tuberculosis as the same 
diathesis. This identity is now denied by many pathologists. A 
distinction is at present generally drawn between the caseous mat- 
ter of softened glands and true tubercles. Yet certain phenomena 
justify the use of the term strumous or scrofulous diathesis. 
"These phenomena are associated with peculiarities of outward 
appearance during life, and liability to certain diseases termed 
scrofulous, such as swellings of lymphatic glands and of joints, 
carious ulcerations of bones, frequent and chronic ulcerations 
of the cornea, ophthalmia, abscesses and cutaneous pustular erup- 
tions, persistent swelling and catarrh of the mucous membrane 
of the nose, and characteristic thickening and swelling of the 
upper lip — lesions which, while they are distinguished by mildness 
of symptoms, are peculiarly persistent, and follow the application 
of exciting causes which would have no effect on a healthy person." 

Scrofula is the term commonly used in the above named local 
affections involving, rather early in life, the glands, bones, nose, 
ears, and eyes. Goitre or bronchocele is an analogous, if not identi- 
cal affection. It is most common in narrow, damp valleys and 
mountainous regions. 

These causes are chiefly hereditary transmission and deprivation 
of pure air* The former is well known to all. Baudelocque, Mc- 
Cormack, and Greenhow, among others, have proved the latter. 
All depression of the system by low living, as insufficiency of food 
and warmth, etc., will produce it. It has been imagined, not 
proved, that the syphilitic taint of constitution may glide into it. 

Treatment. — The use of iodine, variously combined, has the 
general confidence of the profession in the treatment of scrofula. 
Particularly in chronic enlargement, with or without cheesy de- 
posit, and softening of the lymphatic glands, as those of the arm- 
pit, groin, and neck. But it does not always succeed. 

Scrofula is intrinsic constitutional want of normal vitality, or 
innutrition. Briefly stated, the indications are to stimulate up the 
system to a normal state of vitality, and give the proper tone to its 



TREATMENT OF SCROFULA. 193 

I 

general energies, by all available means and measures, on general 
principles. It is manifest in three local forms : 

1. Scrofulous or Strumous Abscesses. — Often commence insidiously 
in areolar tissue. Sometimes become indolent. Suppurate imper- 
fectly. In other cases they burrow deeply, and in all directions. 
Long sinuses, from which exudes a thin sanious pus. Occasional 
extension to the bone— necrosis resulting. General health much 
depressed. Only to be cured by a very nourishing diet ; bark, iron, 
cod-liver oil, and pure air. Iodine and its compounds regarded as 
anti-strumous remedies. "Chemical Food," i. e., the phosphates 
of lime, iron, soda, and potassa, in syrup. 

2. Scrofulous Ulcers. — An indication of the weak cachectic con- 
dition of the strumous system. Most commonly situated about 
neck, shoulders, arms, or hips. Extensive tracts of skin destroyed 
by their gradual extension. Efforts at repair slow and imperfect. 
Granulations absent, or exuberant and flabby ; subjacent tissue 
boggy, and readily broken down by finger or probe. General 
health bad from the beginning, with daily deterioration. Cicatri- 
zation sometimes procured after destruction of the unhealthy tissue 
with strong caustics : nitric acid, or potassa fusa. Ordinary astrin- 

' gent lotions useless. Constitutional treatment most essential. Oc- 
casionally, strumous ulcerations and lupus coexist. 

3. Inflammation and Suppuration of Lymphatic Glands. — One of the 
most frequent results of the strumous habit. Glands of neck 
most liable. Extensive tracts of skin and areolar tissue sometimes 
destroyed. When pus has formed, early evacuation by knife or 
otherwise required. The resulting cicatrix becomes a great dis- 
figurement. Constitutional remedies. See Adenitis. 

Some of the important proper formula for the constitutional 
treatment of scrofula in its manifestations, are : 

#. Ferri Phosphatis, gr. 40 ; Acidi Phosphorici Diluti, fl. drs. 
1| ; Syrupi Aurantii Floris, fl. oz. 1 ; Mucilaginis Tragacantha?, 
ad fl. oz. 8. Mix. One-sixth part three times a day. In scrofula, 
cancer, low nervous vigor , etc. 

¥e. Ferri Phosphatis, gr. 20 ; Pulveris Myrrhse, gr. 15 ; Sacchari 
Albi, gr. 30. Mix, and divide into six powders. One to be taken 
night and morning. In rickets, and all the strumous diseases of chil- 
dren. 



1 94 KACHITIS — RICKETS. 

A syrup of the phosphates of iron, lime, soda, and potassa has 
been prepared by Mr. Parrish, of Philadelphia. It may be obtain- 
ed from most pharmaceutic chemists ; being known as "Chemical 
Food." The dose for a child ten years of age, is one teaspoonful 
in water after the two principal meals of the day. This measure 
contains one grain of phosphate of iron ; two and a half grains 
of phosphate of lime ; and smaller portions of the alkaline phos- 
phates. Chemical Food is a preparation of great value in all forms 
of strumous diseases, arid general debility. 

Rachitis — Rickets. 

Rickets. — Synon. Rachitis ; Osteomalacia Infantum. — A disease 
peculiar to childhood, as osteomalacia is to adults. Usually ap- 
pears to commence about the fifteenth or eighteenth month after 
birth, when the child begins to walk. The bones as they grow 
remain soft and flexible ; they bend under weight of body. The 
osseous tissue looks natural in structure, but is insufficiently im- 
pregnated with earthy salts. Strumous children of the poor mostly 
suffer. 

Symptoms — Pallor ; imperfect digestion ; profuse perspiration 
during sleep, especially about head and face. Ends of long bones 
enlarged ; physiognomy peculiar ; growth stunted ; head usually 
large ; forehead prominent ; fontanelles close slowly. Tonsils 
often enlarged ; chest narrow, with prominent sternum— pigeon- 
breaded. Spinal curvature ; pelvic deformity, so that in after life 
parturition would be attended with great difficulty. Curvature 
of the limbs, especially of lower extremities (bandy-legs). The 
deformed bones become firm after puberty. 

Treatment. — Attention to general habits, exercise, ^and cloth- 
ing. Animal food, milk, raw eggs. Phosphate of lime, phosphate 
of iron, Chemical Food, cod-liver oil, tannic acid, carrageen or 
Irish moss. Light supports for spine, or lower limbs. Bathing 
with salt water, or bay rum. Friction, pure air, and other invigor- 
ating measures. 

Special attention to the*improvement of digestion and assimula- 
tion of nutritious, generous diet is the important object. 



an.emia— poverty of the blood. 195 

Anaemia — Poverty of the Blood. 

Synon. Kvcemia ; Spancemia ; Hydremia; Oligaimia. — Defici- 
ency or poverty of blood. The red globules, instead of existing in 
the proportion of 130 per 1000 parts of blood, as in health, are 
reduced to 80, 60, or even less. The liquor sanguinis is also poor 
in albumen, and may contain an excess of salts. 

Symptoms.— A pale, waxy, blanched appearance of integuments 
and mucous membranes ; feeble, rapid pulse ; anorexia ; aortic and 
pulmonary systolic murmurs; bruit de diable in jugular veins ; en- 
largement of thyroid ; proptosis oculi ; attacks of fainting ; palpi- 
tation and dyspnoea ; oedema, and dropsical effusions into pleura, 
pericardium, or peritoneum; amenorrhcea ; occasionally, fatal 
syncope or coma. 

Treatment. — If possible, ascertain the cause and remove it. 
Hygienic condition is the most important, especially in cases 
of chlorotic ladies. Avoidance of sedentary and other habits un- 
favorable to recuperation and restoration of health. Seek fresh, 
pure air ; out-door, bracing exercise, and cheerful associations. 
Baths and friction* are important, and careful attention to nourish- 
ing, appetizing food, and improvement of the digestive organs. The 
use of meat and nutritious soups are necessary, and chemical food, 
pepsin, etc. The bowels should be regulated with mild aperients, 
given at night, in pill form, consisting of aloes and myrrh. One 
proper stool daily is requisite. Tincture of belladonna and nux 
vomica may secure this. 

Iron in some form is the' great remedy in anaemia. The mist, 
ferri. co. is eminently efficacious in chlorosis, and other excellent 
preparations are the pill, or saccharated powder of carbonate, the 
ammonio-citrate, and the ferrum redactum. The tincture of the 
sesquichloride is invaluable in many cases, especially when the an- 
aemia is associated with excessive discharges. The solution of the 
citrate, phosphate, sulphate, and magnetic oxide of iron are also very 
useful preparations, and, in anaemic children, steel wine and the 
tartrate produce excellent results. Chalybeate waters are bene- 
ficial in some instances. Iron may be combined with infusion 
of hydrastus calumba, or with quinine, or strychnine, or with wine. 
The form of these remedies should be changed from time to time. 
Special or individual symptoms should be treated according to in- 
dications, as they present, at any time. 

16* 



196 leucocythemia — white cell blood. 

Leucocythemia — White Cell Blood. 

Synon. Leucocytosis ; Leuccemia ; White Cell Blood. — We have two 
varieties, L. splenica and L. lymphatica, or Lymphadenoma. A morbid 
state of the blood, in which the white corpuscles are greatly in- 
creased in number, while the red cells are much diminished. Con- 
nected with hypertrophy of the spleen, or of the lymphatic glands. 

Symptoms. — Anaemic pallor ; emaciation and debility ; abdomi- 
nal swelling ; disordered respiration ; loss of appetite ; mental de- 
pression ; diarrhoea ; nausea ; hemorrhage from nose, lungs, or 
stomach; jaundice; anasarca; ascites; prostration, ending in 
death. Pathognomonic characteristics are presence of excess 
of white corpuscles in blood, and great enlargement of spleen or 
of lymphatic glands. Sometimes peculiar inflammation of retina. 

The history of its discovery, which has been subject to controversy, 
appears to be, in brief, as follows : Dr. Craigie, of Scotland, re- 
ported (1845) a case of disease of the spleen, examined also by Dr. 
John Reid, in which a peculiar appearance of the blood occurred, 
supposed by them to be "purulent." Dr. Bennett, of Edinburgh, 
in 1845, published an account of a similar case, describing it as 
"suppuration of the blood." A month later, Virchow, of Berlin, 
described a case, presenting the same appearances, under the mi- 
croscope, as leiikozmia, or white blood, asserting the view that excess 
of the colorless corpuscles, not suppuration, was the true nature 
of the affection. " 

The causes of leucocythaemia are, exposure to cold and wet, pros- 
trating diseases, such as typhus, typhoid, or puerperal fever, and 
affections of the lymphatic glands or of the spleen, but often 
of undetermined origin. 

Diagnosis of leucocythsemia is only possible by microscopic ex- 
amination of the blood. A drop from a needle prick of a finger 
will suffice; placed under a microscope of 250 diameters or more. 
Instead of being but one to fifty or more of the red corpuscles, the 
white blood-cells may be one to six or four ; perhaps even one to 
two or three. When a lager quantity of blood is drawn, it has, 
after heating, a whitish or milky look. Its coagulum is grayish- 
white on its surface, from excess of the colorless corpuscles. After 
death, coagula are found in the heart, consisting of such corpuscles 
almost alone. 



PYJEMIA — BLOOD-POISONING. 197 

Treatment. — No special interference is needed in acute cases, 
unless an abscess should form and be recognized, which must be 
opened or treated in the usual way. Quinine has a marked influ- 
ence in reducing malarial congestion, even after it has existed for 
some time. When there is mechanical congestion any impediment 
must be removed, if possible, but if not, saline purgatives act ben- 
eficially by relieving the vessels. In hypertrophy and leucocyth- 
aemia the chief matter in treatment is to improve the general 
health and blood-state by iron, mineral acids, quinine, etc., as well 
as by a nutritious diet, change of air, and attention to hygienic 
measures. Iodides and bromides have been supposed to reduce 
the size of the spleen, but, so far as I have seen, they are of not 
much benefit. Friction over the organ with iodide of potash oint- 
ment has also been recommended. Extirpation of the spleen has 
been advocated as a last resource. Various symptoms must be 
treated as they arise. Invigorate the system through all known 
means and measures. 

Pyemia — Blood-Poisoning. 

"Absorption of pus" as such, through the walls of bloodvessels, 
was formerly believed to be impossible on account of its cellular 
nature, the pus cells being too large to pass through the capillaries. 
The observations of Cohnheim and others, on the escape of leuco- 
cytes (white blood corpuscles) through the walls of the capillaries 
during inflammation, have modified this view somewhat. Under 
the name pyaemia, indeed, several affections are included : 1. 
Septicemia or ichorhcemia, i. e., blood-contamination from absorption, 
in a liquid state, of putrescent or otherwise morbific material ; 
2. Transfer by veins of actual pus, in cases of phlebitis, and its de- 
posit in new localities ; 3. Thrombosis, or coagulation in a vein, 
succeeded by embolism, or conveying of a portion of coagulum to 
various parts, exciting irritation or obstruction. 

Etiology. — Besides obvious injuries and operations, the causes 
of pyaemia or septicaemia are : 1. Disease of bones, leading to 
suppuration ; 2. Affections of the heart or vessels, originating 
septic materials, as endocarditis, softening of clots, especially in 
the veins, phlebitis ; 3. Formation of abscesses, or grangrene in 
any part ; 4, Ulceration of mucous surfaces, as the gall-bladder or 
its duct, and the intestines ; 5. Inflammation of a low type, and 



198 PYEMIA — BLOOD-POISON. 

attended with suppuration, in the pelvis of the kidney, bladder, 
or urinary passages ; 6. Diseases giving rise to external inflamma- 
tion of an unhealthy character, with the formation of pus, as ery- 
sipelas, variola, vaccinia in revaccination, malignant pustule, glanders, 
carbuncles or boils, and dissection-wounds ; 7. Pyaemia occasion- 
ally arises in low fevers, as typhus, without there being any evi- 
dent local source of blood-poisoning ; 8. Pyaemia may follow a 
very slight injury in unhealthy subjects, and there are many in- 
ternal causes which may escape observation. 

Anatomical Characters. — Death may occur from pyaemia, 
without any characteristic post-mortem appearances. The mor- 
bid changes are : 1. Great congestion throughout the various organs 
and tissues of the body ; 2. Hemorrhages, in the form of petechias 
or vibices in the skin, mucous and serous membranes, or actual 
escape of blood into serous cavities ; extravasations into muscles 
and among deep tissues; and apoplectic clots in the substance 
of organs ; 3. Acute inflammation in the solid organs, of a low type ; 
4. Formation of abscesses in them, of good size, of unhealthy pus, 
resulting either from hemorrhagic clots, inflammation, or slough- 
ing ; 5. Gangrene of portions of organs ; 6. Low serous inflamma- 
tions, with a tendency to purulent effusion, which may be limited 
in abscesses, and the production of unhealthy lymph ; 7. Inflam- 
mation of mucous surfaces, leading to the discharge of pus, ulcera- 
tion, and sometimes to submucous abscesses, or gangrene ; 8. Se- 
vere inflammation of joints, with a great tendency to rapid formation 
of pus, and destruction and disorganization of tissues, both within 
and around the joints, several of them being usually involved ; 
9. Inflammation and formation of abscesses in various parts of the body, 
within muscles, in the cellular tissue, either superficial or deep, 
and sometimes in the skin itself, causing pustules. 

Symptoms. — Sometimes insidious rigors come on abruptly, severe 
and prolonged in character, and repeated at irregular intervals. 
The temperature rises rapidly high, and is usually very elevated 
throughout, but subject to marked and extremely irregular changes. Pro- 
fuse sweating follows the rigors, in the intervals the skin being 
hot, dry, and harsh. There is a marked expression of illness, and 
early prostration, with restlessness or heaviness. The skin soon 
sallow, yellowish, and jaundice sets in ; congestion and petechias 



EMBOLISM — THROMBUS. 1 99 

often, sometimes sudamina, or a vesicular or pustular eruption. 
The digestive organs show great thirst, nausea, and vomiting, fre- 
quently with a glazed or furred and irritable tongue, and fetid 
diarrhoea. The pulse is frequent, feeble, and liable to rapid varia- 
tions. Respiration hurried, and the breath often has a peculiar 
hay-like odor. 

Some local lesions appear in various parts, necessarily differ ac- 
cording to the structures which are affected: the joints are involv- 
ed with considerable frequenc} 7 , becoming very painful and swollen. 
Rapid extreme prostration and adynamia ; low nervous symptoms, 
the face pale and pinched ; the heart's action rapid, weak, irregu- 
lar, and intermittent, the tongue brown and dry, sordes on the 
teeth and gums ; delirium, coma, or rarely, convulsions setting in 
at last, with involuntary discharge of fauces and urine. 

Diagnosis. — It is important to distinguish pyaemia from various 
fevers and acute inflammatory affections it may simulate, and its 
possible occurrence in the morbid conditions mentioned in its 
etiology. In some cases it resembles ague. 

Treatment. — In blood-poisoning the indications are to support 
the system, and depuration of the poison from the blood. Pure 
air is both preventive and curative. The proper remedies are anti- 
septics, tonics and stimulants, such as carbolic acid, the sulphites 
and hypersulphites of calcium, sodium and magnesium, from one 
to four or five drachms of sulphite of sodium may be safely given 
daily ; of the bisulphite about half as much. The free and regu- 
lar administration of nutritious food, stimulants, and tonics, especi- 
ally mineral acids, burk, quinine, and tincture of steel. Anti- 
septics are strongly recommended. Local lesions and special symp- 
toms must be attended to as they- occur in the progress of the case. 

Embolism — Thrombus. 

Embolism.— This signifies a term used to designate the obstruc- 
tion of an artery by a fibrinous concretion detached and transpor- 
ted from the interior of the heart or of some vessel, and carried 
onwards by the blood until the calibre of the vessel becomes too 
small to allow of further progress. The migratory substance is 
called an embolus. 

Symptoms. — They depend upon the organ in which the embolus 
is lodged. A large clot from an inflamed vein fixed in pulmonary 



200 EMBOLISM — THROMBUS. 

artery will induce immediate asphyxia ; or if able to pass on into 
lung, may be the cause of haemoptysis, pleuro-pneumonia, or even 
gangrene. Obstruction of the chief vessel of a limb will induce 
mortification. Plugging of cerebral artery may cause hemiplegia 
and softening of portion of brain ; of renal artery albuminura 

Emboli are, locally apart from their origin, chiefly arterial or 
venous. The arteries most often so obstructed are, those at the 
base of the brain, the internal carotids, the femoral, brachial, 
spleYiic, renal, external carotid, and mesenteric arteries. One ob- 
struction is apt to be the source of others. Cessation of the pulse 
of the arteries in a limb is an early positive sign. Gangrene is 
usually the last and fatal event if an extremity be involved. 

When the right half of the heart has received an embolus, and 
the pulmonary artery is obstructed, collapse of the lungs, partial 
or entire, follows. Pleurisy, hemorrhage, or bronchitis may also 
occur. Or, the symptoms may be, great anxiety and dyspnoea, 
w T ith reduction of the temperature of the body. A systolic mur- 
mur may be heard on auscultation ; the rhythm of the heart be- 
comes irregular; and pulsation of the jugular veins maybe no- 
ticed. Giddiness may be present, with blueness and oedema of the 
hands, feet, or both. Death occurs in much the greater number 
of cases of embolism. 

Where emboli have become broken up and decomposed, septi- 
caemia results — commonly known as pyaemia. The temperature is 
commonly high; from 106° to 107° in the evening exacerbation. 

For treatment of embolism, without septicaemia, our only re- 
sources are, rest, support by food and stimulants, and the alleviation 
of nervous disturbance by soothing measures and remedies. 

Thrombosis. — This term means a clot of blood, and is generally 
understood to be the partial or complete closure of a vessel, by a 
morbid product developed at the site of the obstruction. The 
coagulum, which is usually fibrinous, is known as an autochthonous 
clot or thrombus. 

Thrombi are mostly met with in diseases attended with exhaus- 
tion. Particularly in croup, diphtheria, scarlatina, endocarditis, 
pneumonia, phthisis, typhus, purpura, erysipelas, hemorrhage, etc. 
Their formation is favored by the condition of the blood during 
pregnancy and the puerperal state. 



201 

Treatment. — This must vary according to the symptoms. The 
indications generally are to support the vital powers and allay 
irritability ; brandy, rum, essence of beef, milk, brandy and eggs, 
ammonia, ammonia and iodide of potassium, ether, quinine, bark, 
anodynes, sulphite of magnesia, pure air, perfect rest, etc. 

Melasma Supra-Renalis — Addison's Disease. 

Synon. Morbus Addisonii ; Supra-renal Melasma. — An exces- 
sive degree of anaemia, with bronzing of the skin, supposed to be 
due to scrofulous disease of the supra-renal capsules, which is found 
in caseous condition. 

It is manifestly a cachexia. Probably both the suprarenal cap- 
sular disease and the affection of the skin (olive-greenish darken- 
ing, mulatto-like, or like bronze without the gloss) depend upon 
the constitutional state. Perhaps caries of the vertebrae (scrofu- 
lous), which has been sometimes observed, may, by involving the 
ganglia in disease, thus produce the complex errors of nutrition, 
superficial and general. Dr. Wilks describes the appearances 
of the supra-renal capsule as resembling those of scrofulous lym- 
phatic glands ; a lardaceous material being deposited, which after- 
wards softens into a putty- like mass (grayish translucent material 
with yellow cheesy nodules), or undergoes drying into a chalky 
eoncretion. The disease is fatal always, at last. 

Symptoms. — Commence very, gradually : failing health and de- 
bility, languor, loss of appetite, feeble pulse, irritability of stomach, 
progressive emaciation. Paroxysms of vomiting and gastric irri- 
tation, with faintness ; indications of disturbed cerebral circula- 
tion. A gradual discoloration of skin ; most marked about face, 
neck, arms, circumference of naval ; gradually becoming of a dingy, 
bronzed or smoky hue. This discoloration now said (contrary to 
Addison's original views) not to be a necessary element; appears 
only when case has been of long duration, and perhaps not then. 
Dark patches often present, also on mucous membrane of mouth. 
After an average duration of eighteen months, death from extreme 
anaemia and exhaustion. 

Treatment. — Relieve as far as possible prominent symptoms, and 
adopt best hygienic management, and give good nourishing food. 
Ferruginous and other tonics, phosphorus, iodide and bromide of 



202 STOMATITIS. 

potassium, strychnia, electricity, and stimulants, prescribed with 
care, may in turn prove useful for a time ; to support the system 
in every way and as long as possible, but death at length will end 
your efforts. 



CHAPTER III. 
DISEASES OF THE DIGESTIVE ORGANS. 

The mouth and tongue present important clinical characters, often 
indicative of the general condition of the system, also of the ali- 
mentary canal, and these may be also the seat of local trouble re- 
quiring special treatment. These are characterized, by some or all, 
of the following signs or symptoms : 

1. Change of sensation, such as soreness, pain, heat, dryness, and 
derangement of taste. 2. Interference with the functions of the 
mouth, as sucking, swallowing, and mastication, these often occa- 
sioning pain. Changes in the quality and quantity of the saliva; 
and often discharges of blood, pus, etc. 4. Odor of the breath is often 
offensive, and may become extremely fetid. 5. Mechanical ob- 
struction to the passage of air may occasionally interfere with 
breathing. 6. A careful view of the mouth, with good light, will 
show the color, swelling, deposit, ulceration, and any abnormal state. 
The glands in the vicinity of the mouth must also be carefully 
noticed and treated. 

Varieties. — 1. Simple stomatitis; 2. Aphthae; 3. Thrush; 4. 
Inflamed ulcer or Cancrum oris ; 5. Gangrene of the mouth ; 6. 
Mercurial sore mouth or salivation ; 7. Nursing sore mouth ; 
8. Scorbutic disease of the mouth. 

Stomatitis — Inflammation of the Mouth. 
1. Simple or Folliadar Stomatitis. — Inflammation of the mucous 
follicles of the mouth; it is very common among young children. 
It may be due to the condition of the system, or a result of some 
eruptive or specific fever. 



STOMATITIS — TREATMENT. 203 

Follicular inflammation of the mouth is recognized by small red 
elevations over the tongue, soft palate, etc. This is common in 
infants during dentition ; as well as in adults of impaired general 
health. It requires treatment on general principles. 

2. Aphthae. — These are small ulcers, with whitish surfaces, follow- 
ing a vesicular eruptive inflammation of the mouth. The vesicles 
are small, round or oval, of a pearly appearance, and contain serum. 
They break in a few days, leaving a sore white ulcer, with redness 
around it. They may be scattered or confluent. Fever may attend 
the latter, with disorder of the stomach. Though not common in 
the earliest infanc} T , children sometimes have this disease, but less 
often than adults. Decayed teeth may produce it. On the whole, 
it is to be considered rare. Its duration is generally a week or 
two, but confluent cases may last a month, and have occasionally 
been fatal in a strumous diathesis. 

Symptoms. — Difficulty of sucking ; profuse flow of saliva ; swell- 
ing and tenderness of the submaxillary glands ; fever and restless- 
ness ; loss of appetite ; offensive diarrhoea : small vesicles in the 
mouth, on the fauces, and tongue ; vesicles burst and ulcerate, 
covered with dirty-white or yellowish sloughs. 

Treatment. — When stomatitis is caused by swallowing hot, corro- 
sive, or other irritants, causing thirst, nausea, vomiting, etc., ice 
is the best remedy. Small pieces frequently given, or sucking it, 
until thirst, nausea or vomiting cease, will be eagerly sought and 
enjoyed by the patient. It acts as a direct and efficient sedative, 
affording prompt relief from nausea and vomiting ; it also quench- 
es thirst with less fluid, which is very important. 

Attention to the quality and quantity of the milk supplied 
to the child ; also to the general hygienic condition and sur- 
roundings. R. Boracis, 3j ; Glycerin, fl. 3jss: Aquae rosae, fl. 
3jv. Mix. Apply to gums, tongue, fauces, etc., with a camel's- 
hair pencil, three daily applications. Glycerin is better than 
simple syrup, as sugar favors the formation of fungi, especially in 
aphthae. Mild tonics, as infusion of hydrastus, etc. Carbonate 
of magnesia; chlorate of potash. Treat diarrhoea as such, and 
give special care to cleanliness and good nursing. When the moth- 
er's milk is deficient, or not nutritious, the child should be Fed 
with cracker-water and sweet cream. 



204 STOMATITIS — TREATMENT. 

3. Thrush: Muguet. — This curd-like exudation is conceded to be 
due to a microphic or minute vegetative growth, to which the name 
odium albicans has been given. This condition is common to in- 
fants, occurring after a day or two of diffused inflammation, white 
points appear in the mouth and coalesce, forming patches of whitish 
curdy exudation, unlike aphtha, turning brownish in bad cases. 
The mouth is hot, stomach and bowels are deranged ; vomiting and 
diarrhoea may occur, with more or less fever ; the disease lasting 
from one to three weeks; dangerous only to very feeble children. 
Adults are also liable to thrush, due to a parasitic fungus. 

Treatment.— A mild laxative, as magnesia, or Rochelle salt, to 
clear the prima via, followed with chlorate of 'potassium, have usually 
given favorable results. One to five grains of the chlorate dis- 
solved in diluted glycerin, may be given to a child of five years, 
three to five times daily. Sugar must be omitted because it favors 
the vegetative growth and protracts the disease. Tonics, and a 
nourishing diet, are required in delicate or feeble cases. Stimu- 
lants, as brandy in milk, lime-water and glycerin, are proper in 
these cases. 

4. Cancrum Oris: White. Mouth.- -This begins with ulcers with 
inflamed border on the lining of the lips, cheeks, and gums, and 
may extend to the fauces. These are of a gray or yellowish-white 
color, often causing the cheeks to swell. It causes pain, increase 
and free flow of saliva, offensive breath, and often fever. It is 
seldom fatal, though, if not properly treated, it may continue 
weeks or even months. Children from two to six years are most 
prone to it. It is generally associated with pre-existing disease, 
especially certain acute specific fevers, and chronic exhausting 
maladies, as phthisis, etc., in adults. 

Treatment. — General measures adapted to the condition of the 
case in which it occurs ; similar kinds of local applications as given 
in other forms of sore mouth, may be proper ; also touching the 
ulcers with sulphate of copper twice daily ; intermediate dressing 
with powder of gum arabic and chalk ; washing occasionally with 
glycerin, diluted with rose-water. 

5. Gangrenous— Cancrum Oris : Water Canker. — This is rare, but 
dangerbus; beginning insidiously, it generally first affects the 
inner surface of one or both cheeks, causing a hard, circuscribed 



STOMATITIS — TREATMENT. 205 

swelling, with surrounding oedema. Skin tense, hot, and shining 
red, shading off from the center, occasionally pale or mottled. 
Examination reveals a small, irregular ulcer, with jagged, red or 
livid edges and sloughing. After a time the red central spot turns 
pale, livid, and finally black, converted into a dry gangrene, 
sloughy surface, extending rapidly to the entire cheek, or one-half 
the face or more. At the same time the gangrene is spreading in- 
ternally; the lips, gums and tongue are involved. When the 
sloughs separate and the mouth is opened the teeth often fall out, 
and the bones may be exposed and necrosed. Or the gangrene 
may be limited to only produce a hole through the cheek, ulti- 
mately closing, only leaving a fistulous opening. The glands and 
adjacent tissues are always infiltrated and swollen. If the de- 
structive process is checked, the surface may clean and granulate 
into cicatrization, often leaving great deformity with adhesion 
of parts. 

The general symptoms vary, but even when the disease is exten- 
sive, these are not severe. Much is owing to the patient's previ- 
ous condition. Fever very slight ; skin, usuaUy cool ; pulse, at first 
rather frequent. Food may be taken eagerly, and strength main- 
tained for a considerable time. If the disease persist, there is 
great tendency to prostration, pulse feeble and small ; diarrhoea 
often sets in, with delirium and drowsiness. Death from blood- 
poisoning by absorption, septicamia, or asthemia. When early 
treated, this disease is often quite amenable to remedies and man- 
ageable ; after extensive sloughing the prognosis is very unfavorable. 
Treatment. — As the promotive causes of this very serious disease 
are bad air, "crowd-poison," insufficiency of or improper food, and 
bad habits; these must be corrected, and the constitution invigorat- 
ed and supported. Chlorate, and iodide of potassium should be early 
and alternately employed. Tonics, as quinine, and tincture of 
chloride of iron, keep prostration in abeyance. Nutritious and 
i generous food, with proper stimulation, are indispensible. 

Local applications, at first, astringent lotions, etc., already given 
for stomatitis, should be applied. When the gangrenous condition 
becomes pronounced, a solution of liquor sodne chlorinat. in glyc- 
erin (f3j in f 3ijj) may be applied frequently. Solution of creasote 
in glycerin, or water (gtt. iij to gtt. xx in f3j) may meet the same 



206 STOMATITIS TREATMENT. 

purpose; or permanganate of potassium (gr. x in f3j); or chloride 
of zinc (gr. j in fgj); or suphite of sodium (3j in fgj); or bromine 
(3ss in f3ij), may in turn do best. 

6. Mercurial Sore Mouth: Salivation.— The first effects of mer- 
cury on the mouth are redness, tenderness, tumefaction and disposi- 
tion of the gums to bleed; a peculiar metalic taste ; and a charac- 
teristic unpleasant ordor of the breath. Afterwards superficial 
grayish sloughs and ulcerations form along the margins of the teeth, 
matter exudes, gums detach, the teeth loosen, or even fall out ; 
extensive imflammation of the mouth and tongue ; to ulceration, 
suppuration, or even gangrene. I have seen the tongue protuded 
with inability to retract it. The salivary and lymphatic glands, 
and adjacent structures swell, are all painful about the mouth and 
face; difficulty of swallowing, moving the jaws and speaking. The 
constitutional symptoms are only slight, other than intensely sym- 
pathetic with torturing local trouble. 

Treatment. — Slight salivation will usually recover in a few days, 
in an otherwise healthy person, without treatment. Severe sali- 
vation in scorbutic and other subjects will often tax for a time the 
best skill of experienced physicians. Fortunately for the sick, at the 
present day, the enlightened scale of "conservative practice" crushes 
every fogy who is so far behind our progressive age as to intend 
or attempt to salivate. 

An infusion of sumach ; water and brandy, five parts to one, add 
a little alum, or tincture of myrrh, are good mouth washes in sali- 
vation. Ulcers or sloughs must be treated as in other cases. Fluid 
diet, as milk, cream, etc., must be given while the mouth remains 
very sore and there remains difficulty of swallowing. Nervines, or 
anodynes are usually required while the patient suffers torturing 
restlessness and pain. 

7. Nurses' Sore Mouth.— Ulcerative stomatitis is common to 
women who suckle children, and some of those women who are 
advanced in pregnancy, suffer with this disease. Small, hard and 
painful swellings appear on the tongue, and inside the cheeks 
which ulcerate and are. the source of much local trouble and con- 
stitutional derangement. After the child is weaned the ulcers in 
the mouth usually dissappear. 

Treatment.— If there is constipation, or diorrhoaa, which is a 
frequent cause, or accompaniment, this condition must be corrected 



TONSILLITIS— QUINSY. 207 

by the ordinary remedies and proper diet. The state of consttu- 
tion often requires attention. Tonics, as iron quinine, etc., when 
there is obvious weakness. Chlorate of poiassium, from five to 
twenty grains three times daily, usually has special curative action 
in this aifection. The applications to the mouth should be similar 
to those required for Cancrum Oris, etc. 

Scorbutic Disease of the Mouth has been presented already under 
the title of Scurvy. 

Tonsillitis— Quinsy. 
Tonsillitis. — From tonsilla and itis. Synon. Cynanthe Tonsilaris; 
Inflammatio Tonsillarum; Quinsy; Inflammatory Sore Throat. — Inflam- 
mation of one or both tonsils, with attending fever. 

1. Acute Tonsillitis.— -This is generally caused by a peculiar con- 
stitutional condition, excited by taking cold. Liability to these 
attacks are increased by their repetition. 

Symptoms. — Quinsy begins with chilliness or rigors, redness and 
swelling of the tonsils and fauces, with difficulty and pain in swal- 
lowing. There is also pain along the course of the eustachian 
tube, at the temples, headache and fever. It may terminate in 
resolution in four or five days; it often continues until suppura- 
tion is reached. 

Treatment. — Inhalation of the steam of poppy and hop water, 
or hot spray, with compresses, or sacks of hops and poppy about 
the throat; also warm emollient •poultices; hot foot baths ;. saline 
purgatives, or aperients, as indicated by the state of the bowels, 
such as Rochelle salt, citrate of magnesia, or a solution of acetate 
of ammonia. Opiate and discutient gargles, such a borax, glycerin, 
rose-water and belladonna, etc., are serviceable. If an abscess 
forms, it should be cautiously and freely punctured with a sharp 
pointed bistoury, the cutting edge directed towards the medial line 
of the body; if undue hemorrhage follow the puncture, a strong 
solution of perchloride of iron applied to the opening will staunch 
the flow of blood. Then after this a rapid recovery usually ensues. 

2. Chronic enlargement and Induration. — This may result from acute 
tonsillitis, or in strumous or weakly persons come on gradually. 
Enlargements are often so great as to almost block the fauces by 
the apposition of the glands ; causing difficult deglutition, and 
full inspiration. 



208 PHARYNGITIS. 

Treatment. — Iodide of potassium ointment externally, and in- 
jection of a solution of iodine' into the glands. Internally, the 
iodide of ammonium, and tonics ; and other means to improve the 
system when required. If these fail, portions of, or the entire 
glands, should be excised, or sometimes the glands may be shelled 
out with the finger. 

3. Cancer of Tonsil may become a secondary malady, but this is 
not known as a primary disease. If it threatens suffocation, the 
gland must be removed. Treatment of cancer will receive due at- 
tention in the proper order. 

Pharyngitis — Inflammation of the Pharynx. 

Synon. Cynanche Pharyngea. — Inflammation of pharynx. In 
some mild forms it is quite common ; not very common, as might be 
expected in graver forms. 

Slight sore throat is among the commonest of affections, requring 
for its treatment only mild gargles as alum in flaxseed or sage tea, 
demulcents of flaxseed or gum arabic, slippery elm infusion, fomen- 
tations, and volatile liniment or spirits of turpertine, and a dose of 
a saline cathartic, with diet. With children who cannot gargle, 
finely powdered alum may be blown into the proper fauces and 
throat, through a quill, more readily than in any other way. 

Chronic pharyngits is often a much more tiresome, though not 
dangerons local disorder. The mucous membrane becomes per- 
manently hyperaemic, almost granulated; with either abnormal 
dryness or a thickened secretion, and constant soreness. In the 
treatment of this, all the different astringent, demulcent and alter- 
ative applications may be tried — sometimes without success. 
When nitrate of silver, tannin, sulphpric and muriatic acid, sul- 
phate of zinc, and acetate of lead have been found to fail, it may 
happen that ice, or gargling often with ice-water, or salt-water will 
prove more useful. 

Counter irritation, with repeated small blisters, tincture of iodine, 
etc., is always a suitable and impoatant part of the treatment of 
chronic inflammation of the throat. 

Ulcerated Sore Throat. — This may be idopathic, syphilitic, or 
tuberculous. Thejbrmer is most uncommon. 

The treatment in the first variety consists of the local application 
of blue stone or, lightly touched, solid nitrate of silver to the ulcers 



STRICTURE OF THE OESOPHAGUS. 209 

if within reach. The syphilitic will- require, also, iodide of potas- 
sium internally (gr. v vel x ter die); the tuberculous, tonics, gen- 
erous diet, cod-liver oil, etc. 

Retropharyngeal Abscess. 

This most often follows fever as a sequelae; but is altogether 
rare. It is shown to the careful observer by dysphagia and dys- 
pnoea, much increased by the recumbent posture ; yet not, as in 
croup, increasing from day to day, or disappearing in a short time, 
There is also stiffness of the neck, and swelling on one or both sides 
of it. In such circumstances, a finger passed over the tongue into 
the pharynx may find a firm projecting tumor occupying its poster- 
ior and lateral walls. It may prove fatal, by asphyxia, or by pre- 
venting the patient from swallowing food. When diagnosticated 
in time, the matter may be let out by opening the abscess with a 
lancet, through the pharyngeal wall. 

Stricture of the (Esophagus. 

This is uncommon. Its principal causes are, if structural, cor- 
rosive poisons, swallowed ; or ulceration of the throat involving the 
oesophagus, and contracting upon cicatrization. Functional stric- 
ture may be spasmodic, as in hysteria. Dysphagia, not otherwise 
accounted for, and obvisously low down in its seat, or the rejection 
of food partly swallowed, may lead to a suspicion of structure ; and 
examination with a bougie will fix the diagnosis. For the struc- 
tural affection, there is no appropriate treatment except dilatation 
with bougies made for the purpose, applied for a short period, oiled, 
once or more daily. 

Gastritis. 

Gastritis. — Several important affections of the stomach, more 
or less closely connected with inflammation, are included under 
this head. 

1. Acute Gastritis. — Synon. Inflammatio Ventriculi. — Acute in- 
flammation of mucous membrane of stomach seldem or never arises 
idiopathically. A frequent result of poisoning by mineral acids, 
caustic, alkalies, arsenic, etc. Sometimes produced by swallowing 
boiling water, excessive doses of antimony, or use of mustard 
emetics. 



210 G ASTRO-HEPATIC CATARRH. 

Symptoms. — In gastritis due -to an irritant poison; increasing 
burning pain in epigastrium, aggravated by pressure. Distressing 
nausea ; violent retchings. Accelerated pulse and breathing. 
Great thirst : desire for cold drinks, which are vomited immedi- 
ately. Constipation ; scanty and high-colored urine ; extreme 
prostration sets in quickly. Commonly death from exhaustion. 
In exceptional cases, early symptoms very slight. Disease may 
not be suspected until a few hours before death. 

Simple gastritis, in an acute form, is very rare. Corrosive poi- 
sons almost always involve the intestinal tube with the stomach. 
The most ccommon form of "idiopathic" gastric inflammation is 
"gastro-hepatic catarrh," or a "bilious attack," in which the stom- 
ach, duodenum, and liver are somewhat involved. 

Post-mortem evidences of gastritis are : redness, browner or 
deeper and more livid than natural, and dotted, stellated or arbo- 
rescent, rather than diffused ; moreover, not confined to dependent 
parts; enlargement of bloodvessels ; in acute cases, softening of the 
mucous membrane; in more lengthened ones either softening or 
hardening and thickening ; abundance of thickened mucous ; rarely, 
coagulable lymph ; almost never, pus. 

Treatment. — Whatever in the stomach causes irritation must 
be either neutralized or largely diluted, with mild unirritating rem- 
edies. Purgative enemata, such as: ft. Sodii Chloridi 3j ; Decocti 
Hordei fl 3 12. Mix to form an enema, or warm flaxseed oil 3 8. 
Inject and retain as long as possible. May induce copious evacua- 
tion of the irritating cause. In some cases an emetic of ipecacuanha 
with plenty of lukewarm water, or even the stomach-pump may be 
required. Purgatives are decidedly injurious. Warm anodyne 
fomentations over the stomach and bowels often afford relief. 
Sucking ice, or swallowing frequently small pieces of it, often 
affords marked relief of the heat, burning pain, nausea, vomiting, 
etc., present in acute gastritis. Mucillaginous drinks, iced milk, 
and cream, and rice-water, are proper. During convalescence great 
care in diet is required. Small quantities, at short intervals, of 
farinaceous substances and soups ; milk, cream, raw eggs, ice, etc. 

2. Gastro-hepatic Catarrh.— Catarrhal disorders of the stomach, 
called "bilious attacks," may follow any of the causes of indiges- 
tion, and are quite common to some persons, caused by fatigue, ex- 



TREATMENT GASTRO-HEPATIC CATARRH 211 

posure, wet feet, constipation, dysmenorrhea, torpid liver, depress- 
ing mental exertion, sudden emotion, etc. 

Symptoms, — Nausea, great oppression at epigastrium, or vomit- 
ing of greenish-yellow fluid matters, generally not copious, but 
very acid ; often much bile, sick-headache and dizziness, constipa- 
tion of the bowels, and fever. 

Treatment. — Magnesia is a good, quieting, stomachic, and ca- 
thartic. A bottle of solution of citrate of magnesium drank, will 
relieve many cases. Ice melted in the mouth and swallowed slow- 
ly generally allays nausea, thirst and vomiting. . Rest and absti- 
nence from food and drinks, as nearly as possible, with the other 
means named, will generally effect a cure in the brief period of one 
to three clays. 

A good "preventive or abortive of a "bilious attack," if the bowels 
are open, is bicarbonate of sodium, one -eighth of a teaspoonful, 
and repeat hourly if necessary until relief. Or, if constipation with 
headache exist, Husband's magnesia, one or two teaspoonfuls, to 
clear the prima via. Some cases require a podophyllin pill at night, 
occasionally, to stimulate a torpid liver to normal action. 

Severe examples of gastric catarrh, sometimes spoken of as 
•'gastric fevers." Chief symptoms are heat of skin; quick and full 
pulse ; vomiting, with epigastric pain ; scanty urine loaded with 
lithates. Superficial ulceration of mucous coat may result. Rem- 
edies are rest, low diet, demulcent drinks, mild aperients, efferves- 
cing salines. An emetic of ipecacuanha at commencement. Hot 
fomentations ; poultices ; turpentine stupes, etc. 

Sick headache is usually a modification of the above, in so far as 
the symphatic cephalalgia is especially severe. In some persons 
it is periodic. The treatment above mentioned will be adapted to 
a majority of cases of it 

Acute softening of the stomach is described b} r a few French and 
other writers, as a rapidly prostrating and dangerous affection in 
children, sometimes epidemic. Its symptoms are said to be, at 
first, those of simple gastritis ; then, with or without diarrhoea, 
great agitation, prostration, want of sleep, and insensibility — and 
death in one or two weeks from exhaustion. An irregular fever 
with gastric irritation (gastric fever or infantile remittent) once 
had a regular place in the nosological catalogue among fevers. It 

17* 



212 CHRONIC GASTRITIS— GASTRIC ULCER. 

appears to be scarcely uniform enough for so special a designation 
or consideration. 

3. Chronic Gastritis.— While the same doubt as to the pathologi- 
cal correctness of the name (indicating inflammation) exists in the 
case of this disease as in other "chronic inflammations," an affection 
of some distinctness of character, commonly called by the above 
title, is often observed. With the greatest brevity, we may indi- 
cate its symptomatology by contrasting it with that of atonic dys- 
pepsia : 

in chronic gastritis. in atonic dyspepsia. 

Much epigastric tenderness. Little or no epigastric tenderness. 

Pain increased by active exer- Pain not increased by exercise, 

cise or stimulating food. lessened by stimulating food. 

Vomiting usually. Vomiting rarely. 

Eructation of gas rarely. Eructation of gas commonly. 

Chronic gastritis is apt to be obstinate but not dangerous to life. 

Treatment. — Special derangement of any organ, or function, as 
torpid liver, bowels, kidneys, etc., should first receive particular 
attention. Proper diet and habits are essential prerequisites in 
treatment. If a case prove obstinate after this, mild stomachic 
tonics have been employed, counter-irritatiou over the epigastrium, 
by repeated vesication, will be useful. Internally, nitrate of silver, 
in pill, beginning with gr. J, with gr. J of opium, and increasing 
in a few days or a week, gradually rising to 1 gr. thrice daily, with 
a proportionate quantity of opium, is a valuable medicine. Sub- 
nitrate of bismuth is, for the same condition, lauded by some. 
Most important is a bland diet; lime-water and milk, arrowroot, 
cream, tapioca, sago, jellies, cracker soaked in ice-water, etc., in 
small quantities at short intervals. Ice will often quench thirst to 
better advantage, without disturbing the stomach, than water. 

4. Gastric Ulcer. — Synon. Simple, Chronic, or Perforating Ulcer 
of Stomach. — This is a serious affection, and more frequent in women 
than men, and in poor than rich. Very rare before puberty. The 
ulcer is usually round or oval; seldom smaller than a five-cent 
piece or larger than an half dollar ; sometimes with thickened 
edges, sometimes as if punched out of mucous membrane ; and 
mostly seated on posterior surface, lesser curvature, or pyloric 
pouch. May be fatal by hemorrhage, perforation, or exhaustion. 



GASTRIC ULCER — TREATMENT. 213 

Symptoms. — Liable to some variety. Pain in epigastrium, and 
over lower dorsal vertebrae ; increased by food, especially by warm 
fluids and sugar. Tenderness over small spot in epigastrium ; vio- 
lent aortic pulsations ; eructations of sour fluid ; nausea and vom- 
iting ; loss of flesh ; amenorrhcea in young women, particularly 
if there be hemorrhage. In favorable cases pains diminish as 
ulcer gradually heals ; complete recovery. When a large vessel 
is eroded profuse hasmatemesis 

Where perforation happens, which may occur after a large meal, 
and sometimes, especially in young women, with very slight ante- 
cedent symptoms : Violent pain, spreading from epigastrium all 
over belly. Tympanites ; great anxiety; rapidly increasing pros- 
tration ; painless collapse in a few hours — death. 

Diagnosis.— It is often difficult to distinguish ulcer of the stomach 
from chronic gastritis ; as also from cancer, caries of the spine, and 
aortic aneurism. No hemorrhage accurs in chronic gastritis, caries 
of the spine, nor aneurism of the aorta ; while vomiting blood is 
the only positive sign of gastric ulcer. A tumor at some period 
will make cancer known ; an angular curvature will show spinal 
caries. 

Treatment. — Proper diet is the most important ; such as cream, 
lime-water and milk ; cornstarch, rice, arrowroot, sago, tapioca, 
such as are termed bland. If the patient is feeble, concentrated 
beef or mutton tea should be used in preference to solid food. 
Great care is required in eating: — only small quantities of food 
at a time, and at frequent periods, and of the kind that requires 
the least digestion, and which will be readily absorbed. The rem- 
edies indicated are such as will be most likely to arrest ulceration 
and promote granulation. For this purpose : — subnitrate of bismuth 
grs. ij ; carbonate of magnesia, grs. ijss ; bicarbonate of soda, grs. 
v; gum arabic pulv, grs. jv. M. Take in simple syrup with, or 
after each meal. This checks heartburn and acrid eructations bet- 
ter than any other remedy I have ever issued. The stomach must 
be kept as free from irritation and as quiet as possible, must not be 
suddenly impressed. As the gastric secretion is deficient in gastric 
ulceration, remedies, as substitutes for it, are very important ; such 
as hydrochloric acid and pepsin ; either separately or in combina- 
tion. Sometimes it is better to mix them with the food before 
eating, or taken during meals. Lactic acid has also been used, and 



214 INDURATION OF PYLOROUS, 

the others named to aid in preventing the decomposition of food 
which is apt to occur; small doses of nitrate of silver -combined with 
opium may be required at intervals of four or six hours when there 
is severe and burning pain, and efforts to vomit, until these are 
allayed. Small pieces of ice frequently taken, and the topical ap- 
plication of a bladder containing pounded ice, if the heat and 
burning are great ; or what is usually better, fomentations, alter- 
nated with warm anodyne poultices, are often required. Perfora- 
tion, causing peritonitis, and copious hemorrhage, is a dangerous 
termination. This makes itself known by sudden abdominal 
swelling and diffused pain, followed by collapse. 

If perforation — opium freely to arrest all movements of stomach 
so as to limit extravasation of contents and permit of adhesion. 

5. Induration of Pylorous— Cancer of the Stomach.— Synon. 
Fibroid infiltration of Pylorus: Plastic Livitus; Cirrhotic Inflammation. 
— Consists of an abnormal development of fibrous tissue in sub- 
mucous areolar membrane about the pyloric orifice is the most 
common form ; occasionally the cardiac orifice is the seat of cancer. 
The usual symptoms are pain (in rare instances absent are nearly 
so), often excruciating; epigastric tenderness, about in proportion 
to the pain ; vomiting of food, mucous, and " coffee-grounds," or 
mixed blood or mucous, almost never pure blood ; acidity and other 
symptoms of indigestion : fetid breath ; decided constipation ; 
emaciation and cachectic, almost jaundiced, sallowness of complex- 
ion ; sometimes irritative fever. The diagnosis is made nearly 
certain by the discovery of a tumor; not absolutely so— as the 
tumor may be fibroid and not malignant. 

Cancer of the stomach seldom occurs before' forty years of age. 
Its duration averages about a year : it seldom reaches two years. 
The patient commonly dies by a slow starvation, the stomach be- 
coming incapable of digesting and transmitting food. 

No treatment can avail for the cure of such an affection. To 
nourish by concentrated articles of diet, as beef-tea, milk, etc, and 
to allay suffering by judieious use of anodynes, will be all that we 
can do. It is a frequent form of cancer. 

Cancer of the Duodenum, Ccecum, Rectum and Omentum are much 
more rarely met with. Their possibility must always be remem 
bered in considering the diagnosis of abdominal tumors. 



dyspepsia — appepsla— indigestion. 215 

Dyspepsia — Appepsia — Indigestion. 

Dyspepsia is denied a special place in nosology by writers upon 
diagnosis, yet clinical experience calls for a seperate recognition of 
this as a disease, complex as its pathology is, and diverse as may be 
its symptoms. Of the latter, general description will suffice. 

Symptoms. — The patient feels his stomach all the time, though 
not nearly always with pain. When the latter occurs, it is often in 
the breast, causing suspicion of pectoral disease. Little or no 
tenderness on pressure exists, nor is there much nausea, nor vomit- 
ing. The mouth is clammy, or has a sour or bitter taste. The 
complexion is sallow. - The bow T els are costive, and stools deficient 
in color. Other frequent symptomatic affections are cardialgia 
(heartburn), pyrosis (waterbrash), hypochondriasis, palpitation of 
the heart, headache, and disorders of the heart, headache, and 
disorders of the senses, as diplopia (seeing double), etc. Dyspep- 
sia is not a dangerous, but is frequently a very obstinate disease. 

Pathology. — The functional disturbances above enumerated have 
their seat more or less prominently in different parts of the diges. 
tive apparatus; in the alimentary mucous membrane, glandular 
organs, or muscular, or ganglio-nervous. The distressing gastro- 
intestinal irritation, cardialgia, pyrosis, etc, are located in the 
mucous membrane. Defective action of the liver and enteric glands 
produce constipation, with its consequences ; imperfect secretion 
of the gastric juice and pancreation, like hepatic inaction, impairs 
the whole process of digestion. So does atony of the muscular 
coat of the stomach ; while deficient power of the peristaltic intes- 
tinal contraction is perhaps the most common cause of constipation. 
Insufficient or preverted innervation may originate or intensify any 
or all of these morbid states arid actions. Sometimes this is so 
obviously primary and predominant, as to justify the use, in certain 
cases, of the term " nervous dyspepsia." 

Causes. — The causes of dyspepsia are either one or several of 
the following : too much food, or too little food ; imperfect mastica- 
tion, and hurry in eating ; too little exercise ; too much fatigue : 
excessive study, or emotion of mind ; intemperate use of intoxicat- 
ing drinks, opium, tobacco; druging the stomach too much, and 
taking too much fluid with and without meals, etc. 

Treatment. — The most important is proper^ regimen, regular 



216 DYSPEPSIA — APPEPSIA— -INDIGESTION. 

meals, taking sufficient time to eat; simple* and nutricious food, 
and easily digested ; proper variety by daily change, rather than 
the same day. Some cases require to be confined to stale bread, 
mutton and beef. Sometimes the condition of the stomach is such 
that everything seems to " disagree with it," and what will agree 
with some, will not agree with others. Sensible persons will be 
able to find out what best agrees with their digestion, and avoid 
all else until recovery. Due exercise daily, in the open air on an 
easy riding horse, rather than in a carriage, or in either case, sit 
erect. Batlmig, followed by friction to promote healthy skin action, 
in which the stomach sympathizes largely. Avoid active exercises 
of the mind or body for an hour, at least, after eating a meal. 

Mental conditions and nervous impressions are of great impor- 
tance. Harrassing care and anxious occupation, retard or prevent 
digestion, and render improvement impossible. Often the laying 
aside of business and care; either trival, or due recreation are 
indispensible elements in the treatment. Indications are not uni- 
form in different cases. Tonics, laxatives, and alteratives are more 
uniformly required, also other palliatives in most cases. 

Laxatives. — Rhubarb has been uniformly used to relieve habitual 
constipation, because it is both tonic and laxative. It may lose its 
effect and require an auxiliary of podophyllin, ext. cOlocynth, or 
aloes, with an aromatic added, in pill. Occasionally special indi- 
cations may require sulphur, senna, magnesium, or other simple 
remedies. Tincture of belladonna and nux-vomica combined some- 
times prove efficient in promoting action of torpid bowels ; min- 
eral waters are sometimes beneficial, as a resort to mineral springs. 

Tonics. — Pure vegetable bitters, as hydrastin, gentian, columbo, 
chiretta, etc., are proper direct stomachics. In cases where nervous 
debility is marked, especially when chronic, extract of nux-vomica, 
or strychnia in one-thirtieth or one-fortieth of a grain doses, often 
give satisfactory results, more beneficial or better than any other 
remedy I have employed. In anaemic cases, idode of iron may be 
employed. 

Antacids. — After meals, a pinch of bicarbonate of sodium (gr. v 
to gr. x) or half as much bicarbonate of potassium, or a dessert- 
spoonful of lime-water, will, in case of acidity, contribute much to 
the comfort of the patient. Carbonate of magnesium and aromatic 



ENTERITIS — INFLAMMATION OF THE BOWELS. 217 

spirit of ammonia are preferred by some ; and charcoal has useful 
absorbent powers. Sulphite' and hyposulphite of calcium or so- 
dium, for antiseptic effect, may also be given to allay the after 
symptoms of indigestion. 

Alteratives. — In the commencement of the treatment of a case 
of dyspepsia, in which derangement, and commonly inaction, of the 
liver is most generally present, experience justifies the moderate 
use of podophyllin. It may be given in fractional doses, in such a 
case, say gr. J once daily for a week. Occasionally it may require 
to be repeated, at intervals ; but should never be pushed to excess. 
Nitro-muriatic acid, in 3 or 4 drop doses, acts as a mild tonic, both 
to the stomach and to the liver ; and may well follow podophyllin, 
where hepatic torpor is believed to exist. The same indication may 
be met, although with less certainty, by taraxacum or leptandrin. 
Nitric acid (2 or 3 drop doses) is highly lauded as a tonic by some 
practitioners. 

Cardialgia seems to depend mainly upon acidity, aggravated per- 
haps by the butyric fermentation. Aromatic spirit of ammonia, 
tincture of ginger, and camphor water, as well as the antacids 
above r^anied, may be given for it ; or chloroform, in 5 or 10 drop 
doses, in glycerin or mucilage. 

Gastrodynia is a technical term for stomach-ache, common in dys- 
peptics. Carminatives are appropriate for it ; one of the best 
of these is oil of cajuput, 4 drops at a dose, on a lump of sugar. 
Spirits of camphor, compound spirits of lavender, compound tinc- 
ture of cardamom, and essence of ginger are among the most popu- 
lar preparations for its relief. A mouthful of very hot water will 
sometimes quell the pain. 

Pyrosis is best treated by mild astringents; as oil of amber, 
catechu, krameria, ammonio-ferric alum, creasote (J drop or J drop 
doses), tincture of chloride of iron. 

Dr. Brown-Sequard has lately (1873) proposed, for aggravated 
cases of dyspepsia, treatment by very frequent small portions 
of food, in an easily digested condition. This plan has not yet 
been extensively tried. 

Enteritis— .Inflammation of the Bowels. 

Synon. Intestinarum Inflammatio ; lleocelitis; Enterophilogosk. — In- 
flammation of the small intestines varies much in severity. The 



218 ENTERITIS— INFLAMMATION OF THE BOWELS. 

results are sometimes slight, other times grave. There are no 
signs by which the morbid action can be positively diagnosed as 
existing only in the duodenum, or in the jejunum, or in the illeum. 
Only the mucous lining may be involved, or all the coats of the 
bowel may be included in the inflammation. 

Causes. — Blows or their injuries; exposure to cold and wet; 
neglected constipation ; corrosive poisons ; or a part "of the results 
of strangulated hernia or other intestinal obstruction, etc. 

Symptoms. — Muco-Enteritis, or acute intestinal catarrh, is a form 
of diarrhoea, with bilious and mucous, or later, serous stools. Pain 
in a portion of the abdomen, increased by motion or pressure. 
Rigors denote that the muscular coat is involved; hot skin; thirst; 
hard and frequent pulse ; pain around the navel ; nausea and vom- 
iting. Position, on the back so as to relax the abdominal muscles 
or parietes ; great restlessness ; high fever ; prostration ; anxious 
countenance ; obstinate constipation ; delirium ; wiry and almost 
imperceptible pulse. Vomited matters become very offensive, 
sometimes are stertoraceous, followed by collapse, and death. 

Treatment. — Entire repose of the body in bed is indispensible. 
Clear the bowels with the use of unirritating enemata ; as cathar- 
tics must be avoided. Aconite early to moderate arterial action ; 
later belladonna to stimulate the nerve centres, and skin action. 
When the bowels are cleared, opium in moderate doses to allay 
vomiting, pain, and secure rest. Leeching the abdomen, followed 
by active anodyne fomentations, or poultices, covered with oiled 
silk to retain moisture ; anodyne, evaporating lotions, etc. 

Diet must be soft, no other must be given, as demulcent drinks, 
oat-meal gruel, arrow root and similar ; or when the patient becomes 
reduced, beef tea, milk, etc. When there is a disposition to col- 
lapse, ammonia and ether, brandy and egg mixture. In moderate 
cases recovery is quite certain, but severe ones are quite dangerous. 
During convalescence, pure tonics, as infusion Virginia snake-root, 
hydrastus canadensis, ammonia and bark, tincture of steel and 
cocoanut oil, or it and glycerin; cod-liver-oil, cream, &c. Great 
care is required to avoid relapse. 

Typhlitis. — This is inflamation of the cozcum or caput coli. It is 
quite common after neglected constipation. Peri-typhlitis is a 
more obscure affection, involving a local or circumscribed peritoneal 
inflammation with typhlitis. 



PERITONITIS — INFLAMMATION OF THE PERITONEUM. 219 

Symptoms. — Pain, tenderness, swelling, and dull resonance on 
percussion in the right illiac fossa, with constipation and fever. 

Treatment. — Open the bowels first with enemata of warm saline 
water, aided by mild laxatives, as Rochelle salt, or castor oil seem 
to be indicated. Rest, leeching, followed by fomentations and 
poultices; bland diet and proper attention to the skin and extremi- 
ties comprise the main treatment. Abcess may unavoidably result, 
but with safety if it open externally, but fatally if it rupture the 
peritoneal sac, and escape into that cavity. 

Peritonitis — Inflammation of the Peritoneum. 

Synon. InfJamatio Peritonei. — Inflammation of the serous mem- 
brane lining abdominal and pelvic cavities, and investing the viscera. 
May be acute or chronic. Rarely idiopathetic ; may be dne to 
injury, perforation of stomach or intestines, disease of abdominal 
viscera, etc. : — 

1. Acute Peritonitis. Acute inflammation of peritoneum is. a 
serious disease. Accompanied with pain and swelling of abdomen, 
and severe symptomatic fever. 

Symptoms. Pain, gradually extending over whole abdomen. 
Sometimes dullness and rigors. Fever, with small, hard, long' 
pulse. Fxquisite tenderness of abdomen ; increased by slightest 
pressure, and by any movement ealling abdominal muscles into 
action. Patient lies on the back, with knees bent and legs drawn 
up. Abdomen tense, hot and often tympanitic ; motionless in res- 
piration. Constipation ; nausea and vomiting; dry burning skin; 
rapid feeble pulse ; hurried respirations ; often hiccough ; and 
tongue thickly furred. Countenance expressive of anxiety and 
suffering. After a time, belly ceases to be tympanitic but remains 
enlarged from effusion of serum. When disease is about to end 
fatally, abdomen usually gets much distended ; pulse thready and 
very quick ; face assumes a ghastly expression ; cold clammy sweats : 
and death takes place from exhaustion within eight or ten days of 
onset. 

It is usually rapid ; from the incipient chill to the fatal end, often 
occuyying less than a week, though sometimes two. Simple spo- 
radic peritonitis, however, even in puerperal women, is, with care- 
ful treatment, much more often recovered from than not. 



220 INFLAMMATION OF THE BOWELS— TREATMENT. 

Diagnosis. — The most important point is the discrimination of 
" simple peritonits or metro-peritonits in the puerperal state " from 
puerperal fever. The main difficulty about this is that the latter 
disease includes peritonitis almost as constantly as erysipelas does 
diffiusive inflamation of the skin. 

Morbid Anatomy. — After death from peritonitis, the swollen 
abdomen is found nearly always to contain fluid, often considerable 
in amount, serous, sero-sanguinolent, sero-purulent, or pus. The 
matter may form in a few days ; some facts have made it probable, 
even within forty-eight hours. Adhesions are present, with bands 
and false membranes of coagulable lymph, in various parts of the 
abdominal cavity ; and redness, thickening, and opacity exist to a 
greater extent. 

Treatment. — Veratrum, or aconite for sedation ; open the bowels 
first with a cooling saline purgative then keep them free with the 
same in aperient daily doses. Topics. — In severe cases employ cups 
or beeches, poppyhead, or hop fomentations industriously ; alternate 
with evaporating lotions, as either balladonna, or tincture opii, &c. 
After acute stage, use hemlock, ulmus, or linseed poultices alter- 
nate with discutient liniment. Enemata of warm soap water, if there 
be fcecal accumulations in the colon or bowels, to aid purgation, or 
aperient action. The bowels must be kept cleared. Tobacco 
enema may sometimes be required. Poultices should be large, but 
light, and covered with oiled silk, or changed very frequently to 
maintain warmth. If no leeches have been used, flannel dipped in 
spirits of turpentine may be put all over the belly. Later, if the 
case threaten obstinancy, a large blister should be applied. 

In the early stage purperal peritonitis usually yields to free pur- 
gation with castor oil and turpentine, and in my experience these 
have not failed ; disenfectants should be used. 

Diet : — At first to be restricted to milk and water, tea, arrowroot, 
beef-tea, ice, iced water, barley water. Lime-water and milk. 
When exhaustion sets in, brandy ; aromatic spirits of amonia ; spirit 
of ether ; brandy and egg mixture ; essence of beef ; most perfect 
quiet. Air of sick room to be warm but pure. A cradle over 
abdomen to support bed clothes. Good nursing. 
• 2. Chronic Peritonitis.— Sometimes the sequel of an acute 
attack : more frequently an independent affection. May be due to 
presence of tubercles on peritoneum, — Tubercular peritonitis. 



COPPER COLIC. 221 

Symptoms. — Somewhat obscure. Abdominal pain slight. At- 
tacks of colic ; perhaps fever with obstinate diarrhoea. Tenderness 
and swelling of abdomen. Peculiar rigidity of abdominal walls. 
Nausea. Anaemia and wasting. Abdominal enlargement from 
effusion. When with tubercular peritonitis there is disease of 
mesenteric glands, phthisis, etc., the case rapidly runs on to fatal 
termination 

Treatment. — Attention to bowels ; mild but nutrious diet : milk 
or cream ; cocoa ; raw eggs ; solution of raw meat; cod-liver oil; 
iodide of iron ; quinine of bark ; chemical food ; hypophosphite of 
lime, or soda, and sumbul ; pepsine ; diluted iodine liniment to 
abdominal wall ; iodine and cod-liver oil ointment ; iodide of cad- 
mum ointment ; sea air, or every measure for support. 

COPPER COLIC. 

Copper Colic. — Paroxysmal twisting or gripping pains in the 
belly, due to chronic poisoning by copper. Affects copper-plate 
printers 

Symptoms. — Attacks of abdominal pain, coming on suddenly ; 
aggravated by pressure. Nausea and vomiting. Constipation may 
be absent. Peculiar . sallow hue of complexion : countenance 
anxious: eyes sunken and lips livid. A purple line around gums. 

Other Variaties are : 1 Flatulent; 2. billious ; 3, Spasmodic, 
gouty, or rheumatic ; 4. Lead colic. Some writers mention nephritic 
colic ; due to the passage of small calculi from the kidney to the 
ureter; neuralgia of the bowels may cause colic in about the same 
region. Dysmenorrhea or Uterine colic in females may be either 
neuralgia, spasmodic or obstructive. 

Flatulent Colic may be due to indigestion, as from excess in 
the quantity or quality of the food ;' or cold and wet, arresting the 
balance of " aqueous visceral circulation," indispensible to healthy 
digestion, acrid irritation and gaseous distension cause irregular 
tonic contractions of the bowels, chiefly the colon ; not however 
always thus restricted, the stomach even being sometimes the seat 
of pain. 

In flatulent or crapulent colic the abdomen is distended, but not 
very tender, except after long continuance of the attack There is 
constipation of the bowels; often nausea, with belching of wind, 
•ometimes vomiting ; no fever, A sign of the yielding of the attack 



222 BILIOUS— GOUTY- -LEAD COLIC. 

is audable or palpable rumbling of wind in the bowels ; showing a 
return of the almost arrested peristaltic motion. 

Bilious Colic. — The onset in this form is slower. Nausea is 
greater, and vomiting, of greenish or yellowish (biliary) fluid, is 
constant. The pain may last, with very slight remission, for a 
number of days. The bowels are constipated. There may be con- 
siderable fever, and some tenderness of the abdomen on pressure. 
Meteorism is generally present ; but less in proportion to the pain 
than in flatulent colic. In protracted cases, slight or moderate 
jaundice is quite common. 

The greatest suffering in cases of bilious colic is attended upon 
the passage of gall-stones from the gall-bladder to the duodenum. 
Then, the pain is chiefly in the right hypochoncriac and lower part 
of the epigastric region; and sudden relief follows the escape of the 
calculus from the ductus choledochus into the intestinal canal. In 
other cases, we suppose that the irritant which' gives rise to spas- 
modic pain is acrid, unhealthy bile ; which escapes into the intes- 
tines, and also, through the pylorus, into the stomach. 

Certain persons are particularly liable to such attacks ; a large 
majority of people, indeed, are never subject to them. But pro- 
longed bilious colic is never quite free from danger of inflammation 
of the bowels, or in feeble persons, exhaustson from continued suf- 
fering and inanition. 

Gouty Spasmodic Colic. -In the " gouty diathesis," this is one 
mode in which the disease may invade internal organs. The 
stomach is the most frequent and dangerous seat of it ; the attack 
being commonly called u cramp in the stomach." It is character- 
ized by suddenness, extreme severity of pain, and tendency to cold- 
ness, and general prostration of the system. Repulsion of gout 
from the feet, as by cold applications, may bring it on. 

Lead Colic ; Painter's Colic ; Colica Pictonum. — This disease has 
long been known as the result of exposure to the poisonous influ- 
ence of lead. The name of " dry belly-ache " has also been applied 
to it. The abdomen is shrunken and rather hard ; sometimes knots 
of contracted intestine may be felt. There is no tenderness, the 
pain being lessened or relieved by pressure. The suffering is often 
extreme, with restlessness ; the face and the body being thrown 
into grotesque contortions. Constipation is obstinate ; the faeces, 
when passed, small, dry, and hard. No fever exists. There is a 



BILIOUS COLIC— TREATMENT. 223 

blue line along the edge of the gums. Lead palsy may attend or 
follow the colic. 

Treatment. — In all forms of colic, the indications in common 
are, 1, to open the bowels; 2, to relieve pain and spasm ; 8 to pre- 
vent inflammation ; 4, to prevent future attacks. 

In flatulent colic, we should ascertain if the stomach has just been 
overloaded, or any very unwholesome food has been taken. If so, 
a prompt emetic will be proper; as, a teaspoonful of mustard, or a 
tablespoon ful of salt, in a teacupful of warm water — repeated in 
ten minutes if necessary. Then the antacid laxative, magnesia, 
may be given ; a teaspoonful with ten to twenty drops of essence of 
ginger, or ten flrops of essence of peppermint, five or six drops of 
oil of cajuput, or some other aromatic in corresponding proportion. 
If the bowels are not opened, or relief of pain not obtained, no 
great length of time must elapse without an enema, of castor oil, 
salt, and molasses, or soap, in warm water. 

Should the stomach be much unsettled, and the pain violent, we 
may depend upon the immediate use of an injection to open the 
bowels ; and give by the mouth antacids and carminatives. Thus 
aromatic spirit of ammonia, spirits of camphor, compound spirit 
of lavender, or oil of cajuput may be given, with bicarbonate 
of sodium. Small doses every few minutes will be better retained 
than large ones at long intervals, and will act better. 

Anodynes come next in order. Extreme and sudden cases 
of colic, belonging rather to the spasmodic variety, require them at 
once. Other cases, the majority, are better managed by commenc- 
ing with more corrective remedies, as above mentioned. When 
relief is not obtained Avithout, we must give opium, chloroform, 
ether, or Hoffmann's anodyne. The first is of all the most certain, 
although chloroform, internally used, in J- drachm to \ drachm 
doses, has not disappointed. Paregoric is a very good opiate for 
the same purpose. Pills of opium (especially old pills) may do 
better sometimes, where as much as a grain at once may be needed 
for severe pain. Laudanum is the oldest stand-by, and well de- 
serves its place. Chloral may be tried first. 

It is remarkable how much opium a sufferer with great pain will 
sometimes bear without narcotism. But care must be taken not 
to overdo this, or to give any more than is really necessary ; or. 
the remedy may possibly prove worse than the disease. 



224 BILIOUS COLIC— TREATMENT. 

As important part of the treatment of colic is the use of warm 
external applications. Mustard should come first ; a large sina- 
pism, half and half with flour (if the mustard be of good strength) 
and covered with gauze or thin muslin, over the abdomen. When 
it is removed after making a decided impression, let a little lard, 
sweet oil, or cold cream be rubbed on to prevent further irritation 
of the skin. Then, apply a hot flannel, dry, or wrung out of hot 
whisky and water. For the latter, the best mode is to add to very 
hot water an equal quantity of raw whisky. Such appliances 
should be often renewed, or they grow cold. Some persons have a 
tin vessel constructed to hold hot water, and shaped so as to fit over 
the abdomen. This is very good, if it can be used without its 
weight causing too much pressure. The feet of the patient should 
be kept warm ; if he be able to sit up, or to recline with the legs 
over the side of the bed, a hot mustard foot-bath will be suitable. 

Kneading the abdomen gently with the hand will aid to dispel 
flatus ; but it requires tact not to make it too violent an operation. 
In every case of violent colic, the possibility of liernia must be held 
in mind ; and its presence or absence should be ascertained. 

Infants are especially liable to crapulent colic ; some, during their 
first year, having almost daily or nighty attacks. Very simple 
treatment will often suffice in these ; in children, too, over-medica- 
tion should be even more sedulously avoided than in adults. For 
infantile colic of slight severity, peppermint water, or infusion 
of fennel seed, will frequently be enough, with the application of a 
warm flannel over the stomach. Worse cases may be treated with 
lac assafoetidse ; which children generally take well, if it be sweet- 
ened, in teaspoonful or, for very young infants, half teaspoonful 
doses. Antacids, as bicarbonate of sodium, will assist in giving 
relief. Keeping the bowels regular, never allowing a day to pass 
without an evacuation, is most important in young children. 

Bilious colic may be attended by an inflammatory condition. 
Opening the bowels is a cardinal indication in this as in the flatu- 
lent form. If the stomach will bear it, castor oil and turpentine 
will be the most effectual cathartic. The least unpleasant way 
of taking this is, in thorough admixture with spiced syrup of rhu- 
barb ; two tablespoonfuls of the latter with one of oil, and a tea- 
spoonful of turpentine. Magnesia may be retained better than 



BILIOUS COLIC — TREATMENT. 225 

oil upon the stomach. The same antacid, carminative, and anodyne 
remedies mentioned for crapulent colic, will be suitable in bilious, 
and may require more persevering administration. So, also, 
enemata, mustard plasters, pediluvia, and warm applications to the 
abdomen are of great service. Besides these, however, a special 
indication exists for promoting the hepatic secretion, so that by 
greater fluidity and dilution it may be made less irritating and 
obstructive. A very common treatment, then, is, besides such 
palliatives as have been named, to give podophyllin opium : e. g., 
% to 1 grain of podophyllin with about as much opium, every two, 
three, or four hours. Cups, or, later, a blister, over the liver, may 
be right, if hepatic or cystic inflammation threaten. 

When there is strong reason. to apprehend that the passage of a 
gallstone is the cause of the severe pain, the warm bath, if practi- 
cable, will be useful by promoting relaxation ; and full doses of 
opium may be called for by the patient's agony. Some prefer to 
inhale ether or nitrous oxide, or chloric ether is better often. 

Gouty, or other cramp of the stomach, is generally in need of very 
prompt treatment ; essentially stimulant and anti-spasmodic or 
anodyne. In moderate cases Warner's cordial (tinct. rhei et sennae) 
has the advantage of being laxative as well as stimulating ; from 
a teaspoonful to a tablespoonful may be given at once, in hot water. 
In worse attacks brandy, ether, laudanum, and Hoffmann's anodyne 
are more reliable, with a sinapism over the epigastrium, and a hot 
mustard foot-bath. Subsequent treatment, prophylactic of future 
attacks, as with colchicum or other medication, must be pointed 
out by the nature of each case. 

Lead colic, when rapidly produced, may be treated antidotively, 
with sulphate of magnesium. If slowly brought on, we can do 
much less in that way; although it has been asserted that the 
iodide of potassium has an eliminative power over lead combined 
with the tissues of the body. Alum is confided in by some, for the 
same end, notwithstanding its astringency. Castor oil as a laxa- 
tive ; the warm bath to relax spasm, and opium to relieve spasm 
and pain, are the most important usual remedies in this affection. 
The costiveness being mainly spasmodic, it is not unfrequently 
found that, contrary to its common effect, opium promotes, in lead 
colic, the movement of the bowels. 



226 OBSTRUCTION OF THE BOWELS. 

Prevention of Crapulent and Bilious Colic. — This becomes the dut}^, 
if not the interest, of the physician ; when his patient has been 
relieved, to aid him in escaping returns of the disorder. To pre- 
vent the flatulent form, care in diet and regimen will ordinarily 
suffice. For the more serious attacks of bilious colic, to which cer- 
tain persons are subject, prevention is attainable by the same 
means, along with especial attention to the abdominal movements and 
secretions; i. e., the state of the liver and bowels. 

Obstruction of the Bowels. 

Few maladies present so striking a contrast as this, between the 
facility of pathological explanation after death and the obscurity 
of diagnosis and uncertainty of treatment during life. 

Pathological Varieties. — Dr. Haven has well classified these 
as follows : I. Intermural : a, cancerous stricture ; b, non-cancer- 
ous stricture, viz.: 1, contraction of cicatrices from ulceration, 2, 
contraction of wall of the intestine from inflammation ; c, intus- 
susception ; d, the latter with polypi. II. Extramural : a, bands 
of adhesions from lymph ; b, twists or displacements ; e, diverti- 
cula ; d, tumors or abscesses ; e, niesocolic or mesenteric hernia ; 
/, diaphragmatic ; g, omental ; and /i, obturator hernia. III. In- 
tramural : impacted faces, calculi, coagula, curdled milk, etc. 

Symptoms of Intestinal Obstruction. — These are : persistent 
constipation ; constant vomiting, partly or altogether stercorace- 
ous ; coldness of the skin, prostration, distressed countenance 
(facies Hippocratica), collapse. Local evidences, rather more dis- 
tinctive, are hardness or swelling in one part of the bowels; arrest 
of enemata at a certain point, and of borborygmi (gaseous move- 
ments) in the same way. If the obstruction be high up, suppres- 
sion of the urine occurs, with early vomiting. If it be low down, 
great meteoric distension and stercoraceous vomiting. When blood 
is passed from the bowels, with such symptoms, intussusception 
may be inferred. 

But, at last, & probable diagnosis is all that the nature of the case 
will admit. The differential discernment of special forms of ob- 
struction during life is nearly impossible. 

Prognosis.— Without entering into details, it will be evident 
that all obstructions of the bowels are exceedingly dangerous. The 
most speedily fatal are strangulations and intussusceptions. The 



CHOLERA MORBUS. 22 i 

chronic varieties are liable at any moment to end in complete 
closure. Accumulations may often be got rid of, and thus recovery 
be brought about. 

Treatment. — The simple, primary indication in persistent con- 
stipation with unrecognized cause, is catharsis. Castor oil, sulphate 
of magnesium, are, justifiably, given, aided or seconded by enemata 
of the same or similar purgatives. When the diagnosis of intes- 
tinal obstruction has been well made out, no more cathartic medi- 
cines are to be given ; the reliance then being upon nature and 
opium. This drug may be prescribed in grain or half-grain doses 
every few hours, to sustain a tranquilizing effect favorable to relax- 
ation of the intestinal coats. Besides, we may try large enemata 
of warm water; or inserting a bougie, or stomach-tube, to cathet- 
erize the bowel, as far as the ileo-caecal valve ; or, the Hippocratic 
remedy of large air injection, to distend and dislodge the intestine. 
This has succeeded in several cases of intussusception. 

The question of operating presents itself in many of these cases. 
Of course if there is any evident or suspected hernia, surgical in- 
terference is necessary. Another operation, which might be indi- 
cated, is to open the abdomen, with the view either of removing 
some internal strangulation, or of reducing an invagination. If 
there is any good reason to believe that the former exists, it is 
decidedly permissible to risk opening the abdomen, especially if the 
case seems otherwise hopeless. As regards intussusception, it is 
considered by most authorities only allowable to attempt its reduc- 
tion when the large intestine is involved. Under any circum- 
stances the results are not very satisfactory. 

Scybala, or impacted faeces, or coagula, etc., may be removed by 
a spoon or scoop from the rectum. Prolonged use of the warm 
bath may be tried to relax the system ; and, as in strangulated 
hernia, the tobacco injection may be allowable as an extreme 
resort. Colotomy is now sometimes practiced. 

Cholera Morbus. 
This name has become attached to what in technical phrase may 
be most briefly called idiopathic emeto - catharsis ; i.e., vomiting and 
purging, neither brought on by irritant poisons, nor by an epi- 
demic influence. English medical writers describe it sometimes as 

English cholera; others sporadic cholera. 

18* 



228 CHOLERA MORBUS— TREATMENT. 

Symptoms. — Nausea, and vomiting of greenish or yellowish fluid, 
with rejection of all food and drink ; often, but not always, pain 
in the stomach and bowels ; diarrhoea, with brownish or yellowish 
stools ; debility, and coldness ; little or no fever. Beginning with 
such symptoms, if the attack, not relieved, becomes aggravated, 
cramps in the limbs supervene ; the vomiting and purging become 
more watery ; prostation and coldness deepen into collapse — which 
may be fatal. 

Causes — Warm weather seems to predispose to it, by relaxing 
the mucous membranes and exciting the liver. Direct causes often 
are, indigestible articles of food, as unripe fruit, etc.; excess of or- 
dinary food ; sudden change of temperature, checking perspiration. 

Diagnosis.— From epidemic cholera, it is important to distin- 
guish cholera morbus; as the prognosis is not the same, nor will 
the same treatment answer for both. The difference is seen in the 
bilious vomiting and purging of cholera morbus, and rice-water dis- 
charges of cholera ; the greater nausea in the former ; much more 
tendency to collapse, with blueness, dyspnoea, and suppression 
of urine, in cholera. The presence or absence at the time of an 
epidemic of the latter may complete the diagnosis by confirming 
or correcting the evidence of the above signs. It is only in an 
extreme case of cholera morbus that any real difficulty should 
exist. During, and before and after, the prevalence of epidemic 
cholera, an especial tendency to cholera morbus, as well as to 
diarrhoea, often exists. This, called cholerine, may present more 
near resemblance to malignant cholera than our ordinary summer 
attacks. 

Treatment. — A large sinapism should be at once placed over 
the epigastrium. The following mixture is useful in ordinary sum- 
mer cholera morbus : 

#. Sp. ammon. aromat. f3J ; magnesia optim. 3j ; aquae menthae 
piperitae f3iv.— M. To be shaken when taken. S. — A teaspoonful 
every twenty minutes. 

Few cases will fail to be relieved in an hour or two if this be 
given early. The use of calomel and opium pills is a more com- 
mon practice. 

When the diarrhoea is copious, or the case is seen rather late, 
paregoric may be added to the above ; f3ij or f3ss in the same 



CONSTIPATION — TORPID BOAVELS. 229 

mixture. When purging is very urgent and exhaustive, instead 
of magnesia a like amount of bicarbonate of sodium may be used. 
Infusion of cloves, cinnamon, or ginger may assist to quiet the 
stomach in an obstinate case. After the sinapism, a spice poultice, 
of ginger, cloves, and cinnamon, each a full teaspoonful, with a 
tablespoonful of flour, moistened with brandy, should be applied. 
Ice may be given if thirst be great. 

Extreme prostration may require the use of brandy internally. 
To check the diarrhoea and vomiting when threatening collapse, a 
laudanum and starch enema (40 to 60 drops of laudanum in \ an 
ounce of starch) may be given. 

Constipation— Torpid Liver. 

Etiology. — The immediate cause of this very common symptom 
may be summed up as : 1. Mechanical obstruction interfering with 
the passage of the faeces in some part of the alimentary canal. 2. 
Deficient peristaltic action of the intestinal muscular coat, gener- 
ally due to impaired excitability of the nerves, especially of the 
large bowel. 3. Deficiency of secretions, particularly the intesti- 
nal secretion and bile, or excessive absorption, the faeces being 
hence too solid, while the peristaltic action is diminished. 

This may due to a variety of causes, the chief are habitual neglect 
of the act of defecation, either from carelessness, want of time, or 
undue modesty; indulgence in astringent articles of diet ; habitual 
use of opium ; excess in smoking ; sedentary habits, especially if com- 
bined with much mental work ; enervating habits, especially lying late 
in bed ; anaemia, debility, and want of tone from any cause ; dys- 
pepsia, particularly if there is much flatulence ; most acute febrile 
diseases, as well as various chronic affections, especially those con- 
nected with the nervous system ; uterine and ovarian derange- 
ments ; and the presence of lead in the system. 

Some individuals are predisposed to constipation, especially those 
who are of a slow, lethargic temperament. It is more common in 
females, and is more liable to arise as age advances, though very 
frequent in young women, especially in connection with hysteria. 

Symptoms. — Constipation simply means that the stools are not 
passed often enough, being at the same time generally deficient in 
quantity, and too solid. It is a mere temporary derangement : but 
in others it is the habitual condition. Some often state that their 



230 CONSTIPATION — TORPID LIVER — TREATMENT. 

bowels are regular, simply because they go to stool every day, but 
in reality they suffer from habitual constipation, as they only pass 
small amounts, in an indurated state ; hence the necessity of mak- 
ing close inquiry. The degree of constipation varies much. It is 
common with females, whose bowels are only moved once or twice 
a week ; and sometimes the intervals are even longer, being in ex- 
ceptional cases quite extraordinary. Hence faeces may accumulate 
to an enormous amount in the intestines, distending them greatly. 
When discharged, they are firm, often extremely hard, dry, in 
scybalous lumps or large masses, freqaently pale and unusually 
fetid. Hard excrement may cause irritation, and produce a kind 
of diarrhoea, attended with the discharge of mucus or pus, and 
thus may mislead as to the actual conditions, the faeces being 
retained. The passage of indurated faeces may cause a great deal 
of pain about the anus, with straining, and sometimes discharge 
of blood. When retained, excrement is liable to undergo decom- 
position, thus causing flatulence with pain ; the secretions are in- 
sufficient, as also the motor action of the bowels, and cause dys- 
pepsia, usually of an atonic kind. The mechanical effects of accu- 
mulated faeces are often very serious, causing complete obstruction, 
or ulceration and perforation ; they commonly can be detected by 
examination of the abdomen, which may simulate various other 
abdominal enlargements. As a rule these correspond in position 
and shape to the caecum, or some part of the colon ; they often 
have a doughy feel, yielding to pressure, by which they are some- 
times much altered ; and percussion generally gives a combination 
of dullness and tympanitic sound. In some cases, however, these 
accumulations produce extensive, irregular, solid enlargements, 
considerably resembling cancer. Therefore the possibility of any 
doubtful tumor being due to faeces should always be borne in mind, 
and the effects of aperients and enemata observed, before a posi- 
tive opinion is given. 

Upon the general system, the effects of habitual constipation are 
frequently very marked. It produces a state of nervous depres- 
sion, and, by interfering with digestion and nutrition, may cause 
much wasting and anaemia, as a rule. 

Treatment. — Proper instructions are required : 1. It is impor- 
tant to impress upon patients the necessity of paying attention to 



CONSTIPATION — TREATMENT. 231 

the habit of going to stool daily, at the same hour, and having a proper 
evacuation, because if this is neglected for a long period, it becomes 
extremely difficult to restore the bowels to their normal activity. 
2. Change in diet may assist in removing constipation. Astringent 
articles of food must be avoided. Bran bread, oatmeal cakes, or 
porridge, certainly prove efficacious in not a few cases, and figs or 
rather acid fruits are also useful. Any injurious habits, which 
tend to confine the bowels, must be avoided, and a proper amount 
of exercise be taken. Cold bathing with douching of the abdom- 
inal walls is often beneficial ; and in women with relaxed walls, 
the plan of wearing a broad bandage round the body, firmly ap- 
plied, is very serviceable. 3. The inactivity of the bowels may be 
due to a general want of tone, hence tonics are useful, particularly 
those which improve the tone ; the best are the non-astringent 
preparations of iron, mineral acids with bitter infusions or tinc- 
tures, strychnia, and extract or tincture of nux-vomica. If there 
be lead in the system causing the constipation, iodide of potassium 
is the remedy. 4. Various aperients have to be employed, but it is 
desirable to avoid the habit of taking these, if possible, especially 
those of the stronger kind, and therefore, as soon as 'the desired 
effect has been produced, and the bowels have been properly 
emptied, purgatives should be stopped, and the patient impressed 
with the importance of trying to keep up a regular action by atten- 
tion to the matters already named. 

Among the most efficacious aperients, in these cases, are confec- 
tion of senna or sulphur, taken early in the morning ; compound 
rhubarb or extract of butternut pill ; sulphate of magnesia, in 3^ 
3j doses three times a day, which is often beneficially combined 
with sulphate of iron ; sulphate of potash, particularly recom- 
mended for children ; aloes, in the form of extract, pill or decoction, 
especially valuable if the colon is torpid ; and extract of belladonna 
in doses of Jth to ^th gr. once a day. The last mentioned has de- 
servedly come into high repute, and has been particularly recom- 
mended by Trousseau ; a combination of this remedy with extract 
of nux vomica is very servicable in some cases. Not uncommonly 
it becomes necessary to use stronger purgatives from time to time, 
such as extract of colocynth, podophyllin, jalap, or gamboge. If 
the bile appears to be deficient, podophyllin is valuable, or some 



232 DIARRHCEA. 

recommend inspissated oxgall. Some of these remedies may be 
given in different combinations with advantage, made up into pills 
with extract of gentian or extract of hyoscyamus. It seems best to 
administer these just before or during a meal. Various aperient 
mineral water are often servicable. 

The employment of simple enemata in cases of habitual contipa- 
tion is not employed to the extent which it merits; an injection 
of water, soap and water, or a solution of salt, in the morning, will 
often prove very useful ; if necessary a little castor oil may be 
added. The use of a suppository of soap is a popular remedy in 
some parts, especially in the case of children. It has been recom- 
mended to galvanize the abdominal walls. 

Occasionally, as the result of long-continued accumulation, the 
rectum becomes greatly distended with solid and dry excrement, 
which has to be mechanically scooped out. Enemata of warm 
water and glycerin may be used to aid in softening and breaking 
it down. Then great care is required to prevent a relapse, and 
restore proper action and tone. 

DIARRHCEA. 

Diarrhoea signifies to flow through. Synon. Caprorrhaa ; Cat- 
arrhus intestinalis; Summer or Billions Diarrhoea; Purging.— A relaxed 
condition of the bowels ; as the frequent evacuation of liquid 
stools. It is more a symptom than a disease, requiring direct 
treatment for relief. A malady having so wide a range should be 
thoroughly understood. 

Etiology. — Diarrhoea results either from increased peristaltic 
action of the intestines; an unusually liquid state of their contents,, 
eepecially when due to excessive secretion ; or most commonly both 
these conditions combined. "The exciting causes of these morbid 
phenomena may be thus stated : 1. Irritation of the intestines by 
food, either taken in excess, of improper quality, or having under- 
gone decomposition ; impure water or other liquids ; purgative 
medicines and irritant poisons generally ; excessive or unhealthy 
secretions, especially bile; worms, trichinae, and other parasites, 
possibly vegetable as well as animal ; or retained faeces. 2. Me- 
chanical congestion of the intestinal vessels, owing to some obstruc- 
tion in the portal circulation. 3. Organic affections of the intes- 
tines, viz., enteritis, either acute or chronic; albuminoid infiltration ; 



DIARRHOEA. 233 

and ulceration, 4. Occasionally mere nervous disturbance, as after 
strong mental emotion, or from reflex irritation of dentition, etc. 
5. In some diseases diarrhoea is a prominont symptom, especially 
cholera, typhoid fever, and dysentery. By many it is then regarded 
as eliminatory in its chsracter, for the purpose of carrying off some 
poisonous material ; and the same theory is applied to its occur- 
rence in renal disease, gout, pyaemia, and various fevers ; or when 
it takes place as a critical discharge at the close of pyrexial affec- 
tions. It frequently occurs in the course of certain wasting chronic 
affections, especially towards their termination, aiding in the fatal 
result, especially in phthisis, cancer, splenic or suprarenal disease, 
and Hoclgkin's disease. 6. Diarrhoea is sometimes vicarious follow- 
ing the sudden suppression of discharges, or the absorption of drop- 
sical fluid. 7. There are some causes of a more general character 
of which this is a symptom, as exposure to changes of tem- 
perature, or cold or heat ; foul air, overcrowding, and other anti- 
hygienic conditions ; excessive fatigue ; emanations from decompos- 
ing animal matter ; and malarial influence. The combined action 
of some of these, with improper diet excite the summer and autumn 
diarrhoeas so prevalent at these seasons. 8. Very rarely some fluid 
accumulation may give way into the intestines such as an abscess, 
peritoneal effusion, or hydatid tumor, and produce diarrhoea. 

Characters. — In all cases of diarrhoea it is requisite to ascertain 
its duration ; the number of stools passed in the twenty-four hours ; 
their relation to the taking of food, if any ; and also to inspect 
specimens, if possible, as frequently as may be desired. The prin- 
cipal variations of loose stools are feculent ; lienteric, when they 
contain cognizable fragments of food, in some cases scarcely at all 
changed ; bilious ; serous or waiery, also called a flux ; mucous or 
gelatinous ; bloody ; fatty ; purulent ; chronic or white flux. As a rule 
the materials are more or less mixed, and by examination of the 
characters of the stools, the^cause of the diarrhoea may be often 
determined. Various other digestive disturbances are usually 
associated with it, as indicated by griping or other pains in the 
abdomen, sickness, borborygmi, straining at stool, or an abnormal 
state of the tongue. The stools may irritate the anus considerably, 
when the diarrhoea is long continued and of a watery kind. It 
must be remarked that patients sometimes state they are suffering 



234 DIARRIKEA — TREATMENT. 

from looseness, when on investigation it will be found that there is 
only some local discharge, especially in connection with fistula in 
ano. The association of mucous discharge with retained faces has 
already been mentioned. 

If diarrhoea is considerable or lasts a long time, it necessarily 
produces debility and wasting, in some instances very rapidly and 
to a marked degree. 

Treatment. — The first thing, determine whether it should be 
stopped or not. Sometimes not desirable, provided it is not exces- 
sive, the discharge by the bowels being preservative, as, in Bright's 
disease or portal congestion. Some promote it in certain diseases, 
such as cholera and typhoid. As a rule it is necessary to check it 
entirely or partially. For this end the diet must be strictly regu- 
lated, and this may be the only thing needed, especially in the case 
of children. Milk with farinaceous articles, especially arrowroot 
and corn flour, or weak beef tea thickened with these materials, and 
milk puddings, are the best articles of diet. In children, milk with 
lime-water properly administerad will often speedily put a stop to 
diarrhoea. In some cases a little brandy and water, or a mixture 
of brandy with port wine is beneficial. Not uncommonly an 
aperient is indicated at the outset, with the view of getting rid 
of irritant materials. Castor oil, a saline draught, or Seidlitz 
powder, or a full dose of tincture of rhubarb, are best in these 
cases, and they are often advantageously combined with an opiate. 
Antacids, such as carbonate of soda or magnesia, are beneficial 
when there are irritating secretions. 

Among the direct remedies for diarrhoea, opiates and astringent, 
given either alone or with other medicines, in the form of pill, 
tincture, confection, various powders, enema, or a syrup. An in- 
jection of 15 to 20 minims of laudanum with 3ij of decoction of 
starch for an adult often acts most beneficially. The other princi- 
pal astringent and other remedies are gernnium prepared chalk, 
aromatic confection, catechu, kino, logwood, krameria, alum, dilute 
mineral acids, especially sulphuric, tannic and gallic acids, carbon- 
ate or nitrate of bismuth, chloral, and chloridyne : in chronic cases 
tincture of sesquichloride or solution of pernitrate of iron, sulphate 
of copper, or nitrate of silver. Ipecacuanha is invaluable in cer- 
tain forms of diarrhoea. Among the most efficient combinations 



MAEL.EXA -LXTESTINAL HEMORRHAGE. 235 

will be found neutralizing cordial ; compound chalk, or kino pow- 
der, decoction of logwood with lime-water (especially valuable for 
children) ; dilute sulphuric acid ; Dover's powder, alone or with car- 
bonate of bismuth ; and, in chronic cases, pills, containing sul- 
hate of copper with opium, etc. 

Creasote, carbolic acid, and other antiseptics have been employed 
in certain forms of diarrrhoea, with the view of destroying veget- 
able parasites which are supposed to cause them. 

Local applications to the abdomen are frequently very beneficial, 
in the form of poultices, fomentations, or dry heat. Occasionally 
an adult patient may, by voluntary effort to some extent, suppress 
diarrhoea, especially when it is due to emotional disturbance. 

MEL^ENA — INTESTINAL HEMORRHAGE. 

Etiology. — Most of the causes of melaena are similar to those 
which give rise to hgematemesis, and it will be sufficient briny to 
enumerate them thus ; 1. Traumatic injury. , 2. Diseased condi- 
tions of the blood. 3. Vicarious. 4. Mechanical irritation or 
obstruction, especially by violent purgatives, canthararides, turpen- 
tine, various irritant poisons, hardened faeces, and rough calculi. 
5. Organic diseases, viz., enteritis, ulceration, especially in typhoid 
fever and dysentery, cancer, invagination, piles, prolapsus, fissures 
or fistulae about the anus. 6. Extreme mechanical congestion, 
from portal obstruction, or after heart or lung disease. 7. An ulcer 
eating its way into the intestines, or an aneurism bursting there. 
8. Passage of blood from the stomach into the bowels in connection , 
with hemorrhage into this organ. 

Characters. — When blood appears in the stools it is, as a rule, 
much altered in characters, but this will depend upon its amount 
and source, and the rapidity with which it escapes. When in small 
quantities, coming from the upper part of the bowels and slowly 
iischarged, it is more or less dark, often being quite black, and pre- 
senting a tarry or sooty aspect ; or it may resemble coffee-grounds. 
If from the same source, but copious and speedily removed, it may 
be but little altered, though it is usually of a very dark color. 
When coming from the larger intestines, especially near the anus, 
it is generally quite bright and unchanged. The quantity varies 



236 MEL.ENA — INTESTINAL HEMORRHAGE. 

much, ranging from mere streaks to an amount sufficient to cause 
rapid death. By attending to the quantity and appearancet of the 
blood, its seat of origin may generally be determined, aided by the 
general features of the case, and a consideration of the symptoms 
and physical signs referable to the abdomen, not forgettiog an ex- 
amination of the anus and its vicinity. Care must be taken not to 
mistake the dark color due to bile or iron for that depending on the 
presence of blood. 

Treatment. — The same remedies are useful in melsena as in 
hsematemesis. Absolute quiet is requisite. Oil of erigeron (gtt. 
j. to gtt. x.), and oil of turpentine are in much repute. Enemata 
of iced water are sometimes useful, as well as the application of ice- 
bags to the abdomen, Of course if there is anything about the 
anus causing hemorrhage, such as piles or fistula, surgical attention 
will be required. 

Cholera Infantum — Summer Complaint of Infants. 

This is one of the most fatal affections to which childhood is sub- 
ject, prevailing during the hot months of summer. It seems to be 
a disease peculiar to this country, and very destructive to young 
children in the large cities in hot weather. The peculiar influence 
of high heat in an atmosphere contaminated by " town causes, " 
generates it. In New York and Philadelphia and elsewhere its 
prevalence and mortality coincide with the rise of the thermometer 
above 90°. The period of dentition is particularly liable to this 
disorder ; it seldom occurs alter four years of age. 

Symptoms. — Profuse diarrhoea ; the discharges light colored and 
thin ; soon followed by great irritability of the stomach, constant 
vomiting and purging, languor and great prostration. 

Febrile symptoms are usually present ; as quick, small pulse, 
often tense ; tongue furred, skin dry and harsh ; head and abdomen 
hot, and extremeties cool, or cold. Delirum sometimes occcurs, 
indicated by violent tossiug of the head ; attempts to bite, wild 
appearance of the eyes, etc. As the disease continues, the emacia- 
tion becomes extreme, the eyes languid and hollow, and the feat- 
ures contracted. The child lies in an imperfect doze, with half 
closed eyelids, insensible to external impressions. In some, with 
predominance of cerebral symptoms, death may be threatened after 



CHOLERA INFANTUM — TREATMENT. 237 

a very few hours or days of sickness. In others, copious diarrhoea 
and constant vomiting endanger the same result. In many cases, 
however, without violent symptoms, the child is gradually reduced 
by diarrhoea and inanition. 

If the disease is to terminate fatally, the body becomes cold and 
clammy, of a dingy hue, and often covered with petechse ; the 
tongue is dark, and the fauces dry ; the abdomen becomes tympani- 
tic ; discharges dark colored, profuse snd offensive, resembling the 
washings of stale meat ; at other times they are small and consist 
of mucous, water and undigested food. 

Diagnosis, — Frequent discharge from the towels; intense thirst ; 
excessive nausea and vomiting ; rapid emaciation ; and great pros- 
tration sufficiently characterize this malady. 

Prognosis. — Generally favorable except when the brain becomes 
decidedly involved ; generally in acute hydrocephaloid disease and 
which form is very fatal. Such are more usually the result of neg- 
lect; improper early treatment, or from prior disease of the brain. 

Treatment. — First arrest nausea and vomiting. A broad but 
light sinapism over the epigastrium and abdomen and hot applica- 
tions to the feet. Then the indications for medicine are simply 
correctives. For this purpose a variety of means may be called in 
to use, because the results of medicines are not uniform in different 
cases. Often an infusion of cinnamon bark, with lime water equal 
parts in small frequent doses, cold ; give small pieces of ice ; drink 
no water. If this fail to quiet the stomach add a very little mor- 
phine. In other cases neutralizing cordial readily allays the 
nausea ; bromide of camphor is useful, or an infusion of green peach 
tree leaves or of the inner bark.. If there is much depression, 
tincture of cajeput, ether, or chlorofoform maybe required. If the 
gums are hot, swolen, inflamed, they should be thoroughly severed ; 
this often affords instant relief, and must not be neglected when 
obviously required. 

When the stomach becomes quiet, leptandrin, or magnesia and 
rhubarb, may be used in small doses until the stools show a natural 
color. In the early stage, if the head be hot and stupor be threat- 
ened, cold applications, or evaporating lotions, to the head may be 
proper. Such a state does not often last long. After the sinapism 
cannot be borne and the nausea continues, a spice poultice or plas- 



238 DYSENTERY— BLOODY-FLUX. 

ter should be kept over the abdomen, renewing or wetting it with 
brandy, until the vomiting ceases. 

Diet should be lime-water and milk, arrowroot, farina, beef-tea, 
cracker water and cream, etc. If patient is very w r eak, may 
require a little brandy or other stimulant with the food for support. 
Later, the two difficulties are, to check the diarrhoea, and to over- 
come the rejection of food by the stomach. For the bowels, astrin- 
gents are then called for ; especially logwood, blackberry root, 
geranium, krameria ; aided in serious cases by paregoric in small 
quantities by the mouth, or even by injection into the bowels 
of one, two, or three drops of laudanum w T ith starch. If the stools 
have a "rotten-egg odor," the use of pulvis charcoal will correct 
this, and which is caused by the presence of sulphuretted hydro- 
gen gas, very poisonous indeed. 

Protracted summer complaint affords scope for perseverance and 
contrivance in finding food available for the child. Well-made 
beef-tea agrees with most children. Raw beef, scraped or rasped 
fine, has been found to answer the purpose best with some. 

But all medical treatment may fail in some cases of cholera in- 
fantum, which will speedily recover on being removed from the 
city to the country. The immediate effect of a salubrious air is 
often surprising and delightful. 

Prophylaxis. — This is very clear and simple. A child under 
five years of age ought never to be kept in the closely built parts 
of a large city, in such climate at all events, through June, July 
and August, if it can be helped. Next to a residence for the sum- 
mer, in a high and open country, will be the benefit of frequent 
excursions or visits ; riding or sailing; or even, if nothing else be 
possible, being carried daily into the squares or parks of the city. 

Dysentery — Blood y-Flux. 

Dysentery means difficulty or badness of intestine. Synon. Colitis ; 
Colo-rectitis ; Bloody- Flux.— A specific inflammation and ulceration 
of mucous lining (occasionally also of other tissues) of the colon, 
especially perhaps of lower part of this gut and rectum ; attended 
with febrile disturbance, severe griping pains, mucous and bloody 
stools, and great prostration. Has been improperly termed colitis 
(Colon, the large gut; terminal -Ms) ; cases occurring where ulcera- 



DYSENTERY— BLOODY-FLUX. 239 

tion does not stop at ilio-csecal valve, but extends several inches 
up small intestines. 

Severe dysentery rare in this country. Sometimes breaks out in 
unhealthy localities. In tropics often very fatal. Has been ascrib- 
ed to wet and cold, contagion, malaria, polluted water, intemper- 
ance, deprivation of fresh fruit and vegetables, bad or insufficient 
or salt food, insufficient clothing, etc. 

Varieties. -Dysentery may be acute or chronic ; sthenic or 
asthenic ; endemic or epidemic ; bilious ; ulcerative ; strumous or 
tuberculous. 

Symptoms.- -Acute form : Uneasiness and pain in abdomen of a 
griping character (tormina, from Torqueo, to torture), with frequent 
inclination to go to stool. As ulceration commences, desire to 
empty the bowel becomes more frequent, and is followed by shorter 
interval of ease. Evacuations scanty, thin, mucous, bloody ; mix- 
ed with* small hard lumps of faeces (scybala). The scanty stools pro- 
duce great distress ; griping, and straining without any evacuation 
(tenesmus, to strain) ; peculiarly fetid and dark-colored motions, 
mixed with blood and purulent matter and shreds of lymph ; and 
frequent micturition. Urine high-colored ; gives rise to scalding. 
Sometimes constant desire to micturate, only a few drops coming 
away at a time (strangury). Great constitutional disturbance and 
prostration. 

Often associated with hepatitis and hepatic abscess. May end 
in perforation of the bowel and fatal peritonitis : in rupture and fecal 
abscess : in ichorha>mia and secondary abscesses : in fatal exhaus- 
tion. After healing of ulcerations in favorable cases there may be 
troublesome constipation from contraction of cicatrices. 

Severe and protracted cases may be considered as going through, 
1st, the inflammatory, and 2d, the ulcerative stages. 

Simple acute dysentery is commonly sthenic or active, and 
inflammatory, without early or great tendeney to prostration. En- 
demic or epidemic dysentery (the first name is the more correct) is 
generally asthenic. In this form fever may be absent, or brief, or 
of a typhoid character. Vomiting is not rare in this, as it is in the 
ordinary acute form. Coldness and debility come early. 

Sometimes, in malarial districts, dysentery, like all other mala- 
dies, may be intermittent ; with daily or tertian exacerbations and 
intervals. 



240 BLOODY-FLUX— TREATMENT. 

Morbid Anatomy. — Redness, turgescence, thickening, softening, 
ulceration, suppuration, and occasionally pseudomembranous de- 
posits, are, after death from dysenter}^ found, in various degrees, 
in the rectum, colon, and caecum ; chiefly in the lower bowel. The 
hemorrhage which makes the typical bloody stools, is due to the 
congested and inflamed mucous membrane being constricted, in the 
tenesmus, by spasmodic and irregular contractions of the mus- 
cular coat. 

Chronic variety : — Most intractable. Often causes atrophy of mu- 
cous membrane with degeneration of intestinal glands ; or imper- 
fectly cicatrized ulcers remain in tissues of caecum, colon, or rec- 
tum. Most cases recover. Sometimes, however, patient gradually 
wastes : skin gets dry and scaly: improvement one day with relapse 
the next : discharges of fecal matter, mixed with thin pus and 
blood, most offensive: the exhaustion, pains, tenesmus, etc., ren- 
der death welcome. 

Chronic dysentery presents nearly always ulceration of the rectum 
or colon, or both. The discharges in this may become almost en- 
tirely muco-purulent. 

Causes. — Predisposition to dysentery is common in the latter 
part of summer ; in cities and neighborhoods from the middle 
of July to the end of October. Relaxing heat ; cold and wet ; 
indigestible food: bad water; malaria, etc. 

TreaTxMENT. — In simple acute form there is always constipation, 
or obstruction at the place or part inflamed, hence the plain indi- 
cation is to clear the bowels of all faecal and other matters, and 
maintain aperient action until the local inflammation subsides, in 
any form of dysentery, either acute or chronic. This is the essen- 
tial pathological condition and must be observed throughout the 
the treatment in every case. A proper cathartic is important, one 
that will allay, not increase inflamatory action ; such as a full dose 
of castor oil ; or a compound of senna, jalap and cream of tartar, in 
proportion of one part of each of first two, and two of the latter. 
Aid free catharsis by cold mucillaginous enema, also promote sub- 
sequent aperient action with same. Enamata are very important 
in this disease throughout. If there be great pain, add fluid ext. 
of hyoscyamus 3ss to each injection. When there is nausea and 
vomiting, an emetic is often indicated, as syrup or powder of ipecac. 



BLOODY-FLUX — TREATMENT. 241 

In treating acute dysentery, early attention is as important as 
in cholera. The patient should immediately take to bed, remain 
quiet, hopeful and cheerful. 

The remedy, and which has almost specific action, is 
ipecacuanha in full doses. Give grs. 25 to 30 of the powder 
in a small quantity of fluid, with a little syrup of orange-peel, 
the patient keeping quiet in bed and taking no fluid for three 
hours ; if thirsty, allovv him to suck small pieces of ice. In 
from six to eight hours a smaller dose may be given, this 
depending upon the effect of the first, and the urgency of the 
symptoms, by which also the subsequent repetition of the drug 
must be guided, and it may be required for several days. It 
is proper to give 10 to 12 grains at bedtime for two or three 
nights after the stools appear healthy to prevent a relapse. If 
vomiting persists after ipecacuanha has been judiciously tried, 
hepatic complication or overcharging of the system with 
malaria may be suspected. 

Topics. — Local applications over the abdomen are very im- 
portant and useful, especially warm poultices, fomentations 
sprinkled with turpentine, laudanum, or chloroform, and 
sinapisms. Symptomatic treatment is generally required, such 
as emollient and anodyne enemata, if tenesmus is very severe. 
Apropriate diet requires the most scrupulous care. The best 
I have employed is prepared thus: Lukewarm water and 
new milk, of each one pint; place over a fire in a suitable 
vessel, add a little salt and break a hen's egg into same; keep 
stirring until it nearly boils, then set off and stir until luke- 
warm again, grate a little nutmeg over it. This is palatable 
and nourishing, may be freely taken, and will generally be 
retained, when all else is ejected in most cases of persistent 
vomiting. In the progress of the case beef tea, plain soups, 
arrow root, sago, raw white of eggs, jellies, &c, may be 
allowed in small quantities between the periods of doses of 
ipecacuanha. Stimulants must be avoided, except in typhoid 
cases, when they may be required to a proper extent. As the 
patient improves the food may be cautiously changed. 

19* 



242 BILIOUS DYSENTERY 

There are two forms of dysentery which require a modifica- 
tion of the treatment — the malarious, and the scorbutic. The 
former calls for full doses of quinine, or other antiperiodics, 
alternating with the ipecacuanha; the latter for fresh fruits 
and other antiscorbutics. 

Hygienic measures demand every care, as due ventilation, 
disinfection, immediate removed of the evacuations and their 
destruction. As a means of sound discretion these measures 
are very important, more especially in scorbutic and typhoid 
cases, for obvious reasons. 

In Chronic dysentery, the management most essential is to 
regulate the diet, and attend to sanitary measures for improv- 
ing the general health. Rest of the bowels and body; wearing 
a bandage over the abdomen, or a water belt ; frictions over 
the abdomen with anodyne and irritant liniments ; water com- 
press over the anus, or gentle douching the same ; tincture of 
iodine over the left iliac fossa ; anodyne enemata. Tincture of 
steel in full doses three or four times a day, with 3 to 5 grains 
of Dover's powder at bedtime, often give excellent results. 
Any acute or sub-acute exacerbation calls for perfect rest and 
immediate use of ipecacuanha. Hygienic measures are change 
of air; removal from a malarial district, or from a tropical 
region to a salubrious or temperate one ; the wearing of warm 
clothing ; the use of tepid baths, followed by frictions. Great 
prudence is required to prevent relapse during recovery. 

Bilious Dysentery. — This is a distinct form and is 
quite common in some places, in summer and autumn. If 
this variety of the malady is allowed to continue more than 
ten days, the inflammation is prone to extend and involve much 
of the colon with ulcerations, and the system in a typhoid con- 
dition of great danger. 

Treatment.— The disposition to vomit bilious matters, the 
morbid excitement of the liver, and derangement' of the secre- 
tions generally, indicate that the treatment should begin with 
thorough emesis. Ipecacuanha is best for this purpose and 
should be continued until- the secretory functions are well im- 



DISEASES OF THE CiECUM, ETC. 243 

proved and revolutionized. Then follow with free catharsis 
of an unirritating character, as named in the common form of 
the disease to clear the primae viae of bilious and other irrita- 
ting matters. When this is accomplished the case is usually 
modified to a simpler character and may be treated accord- 
ingly. 

If the case is neglected, or wrongly treated, until it assumes 
a grave nature as above named, a supporting and soothing 
treatment will be required as in a severe form of typhoid 
fever. 

Diseases of the Cecum and its Appendix Yeemiformis. 

The derangement of the caecum and its appendix are natur- 
ally divisible into 1. Functional disturbances; 2. Inflamma- 
tion of its walls, as cmcitis or typhlitis; 3. Perforating ulcer of 
the caecum ; perforation of the caecum and its appendix, due to 
the presence of foreign bodies in it; and 4. Perityphlitis. 

The size, position, connections, arrangement, and functions 
of the caecum render this organ one of peculiar interest and 
importance; its anatomy and physiology should be carefully 
studied and well understood. 

The exact functions the caecum does perform are not yet 
settled or distinctly understood. Its structure and relations 
imply that its contents must necessarily pass slowly through 
this viscus. Tiedmann, Cymelin and others hold that its 
secretions and that of the vermiformis are alkaline in reaction, 
having for its office the conversion of starch into sugar, the 
semi-liquefaction of faeces, and the lubrication of the colon. 
The butyric and lactic acids uniformly present are due to the 
decomposition of the saccharine materials. The caecal con- 
tents soon assume a foecal odor, due to the secretion of a 
volatile oleaginous material. Sulphuretted hydrogen is also 
generated here. 

The caecum sometimes bcamcs (nomcusfy disUrdcd, due 
to various causes. 1 . Dcjcr d( l! i } <. n a ici j: 'c nd t x p r ded 



244 C^ECTIS OK TYPHLITIS. 

colon. 2. Upon a paucity of the caecal alkaline secretion. 
3. Upon a weak state of the caecum itself. These abnormal 
difficulties and distention may be greatly enhanced by the 
presence of calculi, entozoa and foreign bodies. 

Ordinarily, from the impaction of faeces and the accumula- 
tion of gas, pain in the right iliac fossa, more or less 
paroxysmal is complained of, vomiting is of frequent occur- 
rence, numbness and pain in the right thigh, retraction of the 
testicle, and frequent micturition are sometimes observed, due 
to irritation of the last dorsal and genito-crural nerves. 

Cjecitis or Typhlitis. — From ccecus, blind; terminal itis. 
Synon. Typhlitis; Tuphlo-enteritis. — Inflammation of the caecum 
or its appendix may be caused by accumulation of hard faecal 
matter, stones, rinds or skins of fruit, biliary and intestinal 
concretions, balls of lumbrici and oxyurides, etc. The mucous 
membrane of the intestines is more susceptible to irritation and 
inflammation during childhood and adolescence than later in life. 

Symptoms. — In acute form. — Fever, nausea, constipation, 
fullness and tenderness over and about the right iliac fossa, 
and pain, made exquisite by pressure. Position of patient on 
the right side, with trunk bent and knees drawn up to relax 
painful parts. If the peritoneal coat gets involved, evidence 
of general peritonitis will become apparent. The areolar 
tissue around the caecum may also become inflamed (perity- 
phlitis) and cases may go on to suppuration and abscess. 

Inflammation of the veriform appendix due to constitutional 
causes or escape of morbid matter into this part, the symptoms 
are very acute : such as excruciating tormina, tympanitis, 
hiccough and vomiting, obstruction of the bowels, great pain 
extending to the right ovary, or testicle, shooting down inside 
of the thigh. Gangrene and general peritonitis may follow 
and cause death, or a portion of large intestine and caecum 
with appendix may slough off, be passed with stool, and yet, 
strange to know, recovery may ensue. In cases of tubercular 
typhlitis ulceration occurs more frequently in the appendix 
than in the caecum itself. ' 



DISEASES OF THE LIVER. 245 

Chronic Ccecitis. — The symptoms in this malady come on 
slowly and insidiously. It is characterized by failing health; 
weakness; loss of flesh; colicky pains in the right iliac region; 
flatulence; loss of appetite; indigestion; diarrhoea alternating 
with constipation. If the mucous coat ulcerates, mucous dis- 
charges occur, and attacks of hemorrhage. Ultimate exhaus- 
tion usually causes death. Perforation is comparatively rare. 

Treatment. — In the acute form, saline laxatives; copious 
warm enemata, using a long rectal tube ; admister anodynes 
hypodermically; apply hot fomentations assiduously and tur- 
pentine stupes to the abdomen; stimulants, as Champagne, may 
be required if the patient becomes much prostrated. Gener- 
ally, this or similar procedure will fulfill the indications and 
afford relief. Ice-water to allay thirst and vomiting is often 
required, and absolute rest. If symptoms of ulceration become 
manifest, ammonia and bark or quinine and ammonia; egg- 
nog, milk, cream, raw eggs, beef tea and similar nourishment 
is required. 



CHAPTER IY. 
DISEASES OF THE LIVER AND ITS APPENDAGES. 

Clinical Characters. — 1. Morbid sensations connected 
with the liver are referred mainly to the right hypochondrium. 
They may extend across the epigastrium to the left side, or 
shoot in various directions. These include different kinds of 
pain, with or without tenderness, or merely a sense of uneasi- 
ness, fullness, weight and heaviness. Sympathetic pains in 
the right shoulder are very common. 

2. Some important symptoms result from disturbance of the 
biliary functions, the chief being those associated with jaundice, 



246 DISEASES OF THE LIVEIL 

with which they will be discussed. Bile may be secreted in 
excess, or be of bad quality, acting as an irritant, causing 
bilious diarrhoea and vomiting. 

3. Obstruction of the portal circulation leads to mechanical 
congestion of its tributary veins. The obvious clinical 
phenomena resulting from this are those indicating gastro- 
intestinal disturbance, with catarrh and its consequences; 
hemorrhage into the alimentary canal; distention of the super- 
ficial abdominal veins; ascites; enlargement of the spleen; and 
haemorrhoids. After death the veins within the abdomen are 
often found much enlarged and varicose, and the organs pre- 
senting the usual morbid changes which follow long-continued 
venous congestion. 

4. If the liver is enlarged, it sometimes gives rise to 
symptoms by pressing upon neighboring structures, such as the 
diaphragm, vena cava, or duodenum. 

5. Physical examination of the liver may demonstrate either 
displacement, alteration in shape, enlargement, contraction, or 
alteration in its characters on palpation. The general char- 
acters of hepatic tumor are as follows : First. Its seat corres- 
ponds mainly to that of the liver, or there is a history of its 
having grown from this direction; it does not descend into the 
pelvis, but can be traced within the margin of the thorax, and 
appears superficial; sometimes it is distinctly visible, or bulges 
out the lower part of the chest. Second. Though the dimen- 
sions may be very great, yet, as a rule, the normal general 
outline of the liver can be traced more or less distinctly; while 
the sensations on palpation are often sufficiently character- 
istic. Third. The organ is somewhat movable on manipula- 
tion, but not to any marked extent. Fourth. On percussion 
there is absolute dullness, with considerable sense of resistance 
generally; the dullness can be traced upwards towards the 
chest, and may have the curved outline characteristic of the 
liver; it is, however, influenced by different degrees of 
distention of the stomach and bowels. Fifth. The move- 
ments of the diaphragm are often interfered with, especially 



DISEASES OF THE LIVER. 247 

on the right side, but the liver is generally altered in position 
by deep breathing. Sixth. Posture may influence the organ 
also, it being more prominent and lower in the abdomen in 
the standing posture. 

6. Occasionally the gall-bladder presents an enlargement, 
with the following characters : First. It occupies generally 
the right hypochondrium, and can be felt coming from under 
the margin of the liver, appearing to be superficial; occasion- 
ally, however, it is so much enlarged as to extend down to the 
crest of the ilium. Second. As a rule the shape is pyriform, 
with the base towards the surface. Third. The surface is 
generally smooth, and has an elastic or fluctuating feel. 
Fourth. Almost always the tumor is very movable from side 
to side, turning on a fixed point, which is under the liver; 
even a change of posture may alter its position considerably. 
Now and then it is fixed by adhesions. 

Hepatalgia. 

The occurrence of intermittent attacks of severe pain in 
connection with the liver has been attributed, especially by 
Dr. Anstie, to a simple neuralgia in some instances. This 
affection is but a part of a general nervous condition, attended 
with similar pains in other parts, and deep mental depression. 
The attacks are not accompanied with vomiting, but there 
may be jaundice. The main difficulty in diagnosis is to 
separate this pain from that due to the passage of a gallstone. 

Jaundice — Tcterus. 

Jaundice is another of those symptoms which has been 
dignified by being described as a special disease. Essentially 
it merely means the peculiar discoloration of skin and other 
structures, which is observed when the bile-pigments accumu- 
late in the blood. 

Etiology and Pathology. — Cases of jaundice have long 
been divided into : First Those in which there is a mechanical 
obstruction to the escape of the bile through the ducts. 
Second. Those in which there is no obstruction. 



248 DISEASES OF THE LIVEIt. 

1, Jaundice from Obstruction. — This may be due to: First, 
Impaction oj some, foreign body in the hepatic or common bile- 
duct, viz., gallstones, thickened or gritty bile, rarely parasites, 
either formed in the liver or its duct (distoma hepaticum* and 
hydatids), or having entered from the intestines (roundworm), 
very rarely fruit-stones or other bodies which have passed into 
the duct from the bowels. Second. Catarrh of the mucous 
membrane of the ducts, or of the duodenum about the orifice, 
causing narrowing of the calibre. Third. Organic changes in 
the walls of the duct or at the orifice, leading to more or less 
stricture, even to complete obliteration, viz., congenital con- 
striction or closure, thickening of the walls from inflammatory 
changes, perihepatitis, cicatrization of an ulcer either in the 
duct or duodenum. Fourth. Pressure upon the duct, invasion 
of its canal, or closure of its opening by tumors, &c, especially 
by projecting growths from the liver, enlarged glands in the 
portal fissure, and pancreatic disease involving the duodenum; 
rarely by pyloric tumor, growths in or behind the peritoneum, 
hepatic aneurism, fecal accumulation in the colon, uterine and 
ovarian enlargements including pregnancy and renal tumors. 
Fifth. Functional disturbance of the muscular coat of the duct, 
in the way of spasm or paralysis. 

Physiologists differ as to how the bile is secreted. This 
influences opinions as to the pathology of jaundice in cases of 
obstruction. It is generally maintained that both the bile- 
acids and pigments are formed in the liver; some believe, how- 
ever, that the latter are produced, either partly or entirely, in 
the blood, and merely separated by the liver. Hence arise the 
two theories : 1. That the discoloration of jaundice is due to 
excessive absorption of the bile by the veins and lymphatics after 
its formation. 2. That it results from suppression of its secre- 
tion, and hence retention of the pigment in the blood. The 



*The distoma hepaticum, or liver-fluke, is a small trematode worm, often 
found in sheep, very rarely in the human being, occupying either the gall- 
bladder or bile-ducts. It is of a flattened, elongated, oval form, soft, and 
brownish or yellowish in color. • 



DISEASES OF THE LIVER. 249 

former is probably the correct view, and the intensity of the 
jaundice will be in proportion to the rapidity with which the 
secretion of bile is going on, and to the slowness of its decom- 
position in the blood. Absorption is always proceeding 
during health, but the bile thus taken up is speedily changed, 
in the process of digestion and nutrition. 

2. Jaundice without Obstruction. — The conditions under 
which this variety is supposed to occur are : First. In certain 
specific fevers, viz., yellow, remittent, intermittent, and relaps- 
ing fevers; very rarely in typhus, typhoid, or scarlatina. 
Second. When certain poisons are present in the blood, 
especially in connection with pyaemia, snake-bites, poisoning 
by phosphorus, mercury, copper or antimony, inhalation of 
chloroform or ether. Third. In acute or chronic atrophy of 
the liver, or destruction of its tissue from any cause. Fourth 
In Congestion of the liver. Fifth. From disturbed innervation 
especially after sudden intense mental emotion. Sixth. When 
the blood is insufficiently aerated, as in pneumonia, new-born 
infants, or as the result of overcrowding and bad ventilation. 
Seventh. Where bile is formed in much excess. Eighth. In 
cases of habitual or long-continued constipation. Ninth. In 
certain states of the portal system of veins, as when they con- 
tain abundant pigment granules, or are unusually empty after 
profuse hemorrhage from the alimentary canal. Tenth. As an 
epidemic. 

The views of different writers as to the pathology of the 
various forms of the non-obstructive jaundice are, that it is 
due 1. To suppression of secretion. 2. Increased absorption, 
so that more bile enters the blood than can undergo decompo- 
sition, either from excessive secretion, undue retention of bile 
in the intestines owing to constipation, or diminution of pres- 
sure in the portal vessels. 3. Impaired and delayed meta- 
morphosis of the bile elements in the blood, and some think 
that the bile-acids are converted in this fluid into bile-pig- 
ments, owing to imperfect oxidation. 4. Conversion of the 
haematine of the blood into bile-pigments. Nervous disturb- 



250 DISEASES OF THE LIVER. 

ance in producing jaundice may affect the activity of the 
secretion, the state of the portal veins, or the rapidity of the 
changes in the blood. \ 

Jaundice is not a necessary accompaniment of even grave 
organic disease of the liver itself, and, in such cases, when it 
is very marked it generally results from some projection from 
the organ interfering with the main ducts, or from the glands 
in the fissure being iuvolved. It may be due to destruction 
of the liver tissue, or to the ducts or the circulation in the 
interior of the organ being interrupted. 

Anatomical Characters. — In jaundice not only are the 
skin and conjunctiva more or less stained with bile-pigment, 
but also most of the other tissues, organs, and fluids of the 
body, as well as morbid exudations and effusions. In the 
skin the pigment exists chiefly in the rete mucosum, also 
involving the sweat-glands considerably. The nerve-tissues 
are but slightly affected, and the general mucous membranes 
with their secretion still less. The bile-pigments are found 
in the clot and serum of the blood, but not the acids; in pro- 
longed cases coagulation is imperfect, and the corpuscles are 
altered in their characters, while not uncommonly there are 
extravasations of blood. In cases of obstructive jaundice the 
liver itself becomes at first enlarged uniformly, without any 
alteration in shape, and mottled of a more or less deep yellow 
tint, in some cases being olive green ; its ducts are distended, 
and in time numerous particles of pigment are seen in the 
cells. Should the obstruction be in the common duct, the 
gall-bladder will be enlarged. If the obstruction is persistent, 
the liver undergoes degeneration, becoming atrophied, very 
dark, sometimes almost black, and softened, many of its cells 
being destroyed, leaving only a granular detritus under the 
microscope. The kidneys also are much changed in prolonged 
cases, being deeply colored, their tubules containing a black 
or brown deposit, and their secreting cells presenting granules 
of pigment, or ultimately breaking down. 

Symptoms. — Usually the first signs are afforded by the 



DISEASES OF THE LIVER. 25l 

urine, next by the conjunctivae, and then by the skin. The 
conjunctivae are more or less deeply tinged yellow. The skin 
may present a variety of tints, from a faint yellow to a brown- 
ish or blackish-green. The color is deepest where the epi- 
dermis is thin, and varies with age, complexion, amount of 
fat, etc. If the lips or gums are compressed, so as to expel 
the blood, a yellowish hue is often observed. The urine has 
a color ranging from a light saffron-yellow to one resembling 
mahogany or porter; on standing it usually becomes greenish. 
Its froth is yellow, and it will tinge white linen or blotting- 
paper dipped into it, often staining the underclothing. Chem- 
ical examination is most important, as indicating the presence 
of bile-pigments, and, as many believe, of bile acids. The 
former is tested for by nitric acid. Either a few drops of 
urine and acid may be placed on a white porcelain surface, 
and allowed to come into contact; or a little urine may be 
poured into a test-glass, and the acid allowed gently to run 
down its interior, so as to sink to the bottom. A play of 
colors is observed, to violet, green, blue and red, these soon 
disappearing. The bile-acids are detected by adding a frag- 
ment of lump-sugar to a little urine in a test-glass, and then 
pouring in a small quantity of strong sulphuric acid, drop by 
drop, alowing it to trickle down the side of the tube. A deep 
purple color is produced where the acid and urine meet. 
Another important character is, that the urine often contains 
leucin and tyrosin, crystals of which may be seen under the 
microscope after careful evaporation of some of the excretion 
to a syrupy consistence. In some cases the quantity of urine 
is deficient at first ; the reaction is acid ; the proportion of 
urea and uric acid varies, and they may be in excess. In 
advanced cases sugar sometimes appears. Renal epithelium 
or casts tinged with biliary coloring matters are occasionally 
observed. 

When the bile does not reach the intestines, the consequences 
are constipation, with unhealthy stools, these being deficient in 
coloring matters, often pale drab or slate-colored, dry, often- 



252 DISEASES OF THE LIVEB. 

sive, and containing excess of fat ; formation of much foul gas 
from decomposition, with, consequent flatulence, and passage 
of fetid flatus. Occasionally diarrhoea is observed from time 
to time, or dysenteric symptoms. There is usually a disin- 
clination for food, especially for fatty matters, and eructations 
are common, which may have a bitter taste. Evidence of the 
presence of bile is often afforded by the sweat, milk, saliva, 
and tears. From the accumulation of bile-acids in the blood 
result not uncommonly cutaneous itching, which may be 
very distressing; slowness of the heart's action and pulse, 
which may fall to 50, 40, or even 20 per minute ; also a feeling 
of languor, depression, and debility, lowness of spirits, with 
incapacity for exertion, irritability, and drowsiness. The 
symptoms last mentioned are also partly due to the emaciation 
and impaired nutrition, which usually become soon apparent, 
in prolonged cases being very marked. In some instances 
urticaria, lichen, boils, carbuncles, or petechia? are observed. 
Yellow vision ( xanthopsy ) is an extremely rare phenomenon 
and its cause is very uncertain. 

Jaundice, especially the non-obstructive variety, may be 
accompanied with symptoms indicative of the " typhoid 
state," low, nervous symptoms, or dangerous hemorrhages, 
particularly from the stomach and bowels, ending speedily in 
death. It is important to observe that these phenomena are 
out of proportion to the intensity of the jaundice. They have 
been attributed to the accumulation in the blood of bile-acids 
or their formative elements, or of some noxious substance 
formed in the cells of the liver ; or to the metamorphosis of 
materials in the process of preparation for excretion by the 
urine being checked or modified, owing to a deficiency of bile, 
which is required for these changes ; so that instead of urea 
and such compounds, intermediate products are formed, which 
collect in the blood and act as poisons. In some of these 
cases the above symptoms are independent of the jaundice, and 
result from some general morbid state, or some condition of 
the kidneys, which leads to blood-poisoning. 



DISEASES OF THE EIVEE. 253 

Physical examination in cases of obstructive jaundice 
reveals enlargement of the liver, not great, and quite regular. 
If the common duct is obstructed, the gall-bladder may also 
present a fluctuating enlargement. Im prolonged cases the 
liver may show the physical signs of atrophy. 

The course, duration, and intensity of jaundice vary greatly, 
according to its cause. It may be merely a slight temporary 
disturbance, or permanent and extreme in degree. 

Diagnosis. — The first matter is to be certain that there is 
jaundice. The discoloration of the skin might possibly be 
simulated by a chlorotic tint, the cachexia of chronic lead- 
poisoning, malaria, or cancer, the color associated with 
suprarenal disease, or bronzing from exposure to the sun. 
The conjunctivae and urine should always be particularly 
examined. It must be remembered, however, that the yel- 
lowness due to the collection of fat under the conjunctivae 
may be mistaken for that of jaundice. Also pigments form 
in the urine sometimes, which render it very dark ; and now 
and then malingeres purposely stain the skin and add color- 
ing matters to the urine. 

It may be difficult to determine whether jaundice is of the 
obstructive or non-obstructive variety, but the latter, as well 
as its particular cause, may be generally recognized : 1. By 
the circumstances under which it occurs, and the other symp- 
toms which accompany it. 2. By the discoloration being less 
marked. 3. By the presence of more or less bile in the stools. 
4. By examination of the urine, as already stated, giving^ indi- 
cations of the presence of bile-acids only in the obstructive 
form of jaundice, though many deny this, and which in the 
non-obstructive variety yields leucin and ty rosin. 

The precise cause of obstructive jaundice is determined by: 
1. The age, sex, habits, and general past history of the 
patient. 2. The preceding and accompanying symptoms, 
both local and general. 3. The rapidity with which the 
jaundice has set in and its intensity. 4. Careful physical 
examination of the abdomen. 5. The course and progress of 



254 DISEASES OF THE LIVER. 

the case and the effects of treatment. The gall-bladder being 
enlarged or not, will show whether anv obstruction exists 
with the hepatic or common bile-duct. 

Prognosis. — As a rule, it may be stated that non-obstruc- 
tive jaundice is much the more grave. Typhoid and low 
nervous symptoms are highly dangerous, as are also hemor- 
rhages, and signs of interference with the renal secretion. In 
obstructive cases not only will the prognosis vary with the 
cause of jaundice, but also with the rapidity with which it 
comes on, its intensity and mode of progress. In every case 
a cautious prognosis should he given, as it is never certain 
how it may turn out, and this is particularly true if jaundice 
sets in rapidly and becomes speedily intense. 

Catarrhal jaundice generally soon disappears. Of course 
when it is due to obstructive organic disease, especially cancer, 
there is no hope of recovery, but it is astonishing what an 
extreme degree the discoloration may attain in some instan- 
ces, without any proportionate general disturbance to lead to 
the idea that bile acts as poison. Jaundice in pregnancy is 
considered highly dangerous. 

Treatment. — 1. Treat the condition upon which it de- 
pends, and remove any obstruction to the flow of the bile, if 
practicable. 2. Promote secretion of bile, if necessary, by 
remedies to be considered; or on the other hand to limit its 
formation. 3. Attend carefully to the diet, especially avoid- 
ing fatty and oily substances, as well as much starch, sugar, 
or alcoholic stimulants. 4. Treat the symptoms due to the 
absence of bile from the alimentary canal, especially constipa- 
tion and flatulence ; or supply a substitute for this secretion 
in the way of artificially-prepared inspissated ox-gall, in from 
5 to 10 grain doses, given 2 or 3 hours after meals. 5. Pro- 
mote the renal and cutaneous secretions. 6. Attend to the 
general condition, giving quinine, iron, and other tonics, and 
always adopt hygienic measures tor improving the health, 
in chronic cases; treating adynamic symptoms by stimulants; 
low nervous symptoms by encouraging free elimination by 



DISEASES OF THE LIVER. 255 

the bowels, kidneys, and skin ; hemorrhages by astringents. 
In cases of permanent obstruction, it has been proposed to 
make an artificial fistula in the gall-bladder, having first 
excited adhesion with the abdominal wall by means of escha- 
rotics. The irritation of the skin may demand measures for 
its relief; alkalies and opiates or morphia internally, or the 
latter hypodermically, and warm and alkaline baths are 
most serviceable for this purpose. It must not be forgotten 
that the color of jaundice remains for a time after any cause of 
obstruction has been removed ; and if this has been effected, 
it is not necessary to continue further active measures. The 
removal of the bile from the system may be promoted by 
occasional alkaline baths, aperients, and mineral waters, while 
convalescence is promoted by hygienic and other measures 
for iniDroving the health. 

J. o 

CONGESTION OF THE LIVER— HYPEREMIA. 

Etiology. — Active hepatic congestion occurs to some de- 
gree during every period of digestion. As a morbid condition 
it is met with : 1. After errors in diet, especially habitual 
excess in eating or indulgence in too rich articles, abuse of 
alcohol or hot condiments, particularly in those who take lit- 
tle exercise. 2. As the result of continued exposure to exces- 
sive heat in tropical climates, or of a sudden chill while 
heated. 3. In connection with malarial, yellow, relapsing, 
and other fevers. 4. Vicarious menstruation, or other 
habitual discharges, as bleeding from piles. 5. As the result 
of injury. 6. Associated with morbid deposits in the liver 
and the early stage of inflammation. 

Mechaniccd congestion is generally due to some condition of 
of the heart or lungs, which interferes with the general 
venous circulation; very rarely to local obstruction of the 
hepatic vein or inferior vena cava. 

Passive congestion follows habitual constipation, or re- 
sults from a torpid state of the portal system, from paralysis 
of the coats of the vessel, or any other cause. 



256 DISEASES OF THE LIVER. 

Anatomical Characters. — It is only the mechanical 
form of congestion that is generally seen after death. The 
liver is enlarged more or less, quite uniformly, its surface 
being smooth, and the capsule stretched. It often feels 
unusually firm. On section an excessive quantity of blood 
flows, the color of the surface is dark, sometimes even pur- 
ple, and the vessels appear abnormally filled, being in time 
dilated. The dark color is rarely uniform, but appears 
chiefly in connection with the intralobular branches of the 
hepatic veins, constituting the so-called hepatic congestion. 
Portal congestion is the term applied when the vessels at 
the circumference of and between the lobules are most dis- 
tended, but it is rarely seen. 

Nutmeg Liver. — It is named from a section presenting a 
variegated appearance, resembling that of a nutmeg, being 
a mixture of red, white, and yellow tints. The condition is 
observed after congestion from cardiac obstruction has lasted 
for some time, and it depends on the following pathological 
changes. The branches of the hepatic vein are distended and 
overloaded, deep red and well defined ; the circumference of 
the lobules corresponding to the portal branches is anaemic, 
and has undergone degenerative fatty changes, hence being 
pale and opaque ; while the bile is stagnant in many of the 
smaller bile-ducts, by which the yellow tint is produced. 

Symptoms. — Local congestion produces a sense of uncom- 
fortable tension, fullness, and weight, especially after meals 
and when lying on the left side; sometimes there is slight 
tenderness. There may be pain in the right shoulder. Slight 
jaundice is often present, but the stools contain bile. The 
spleen becomes enlarged iu time. The alimentary canal is 
deranged as impaired appetite, foul tongue, constipation or 
diarrhoea, and flatulence ; often the result of the same cause 
which produces the hepatic congestion, it may be partly due 
to deficient or unhealthy bile. Some general disturbance 
often accompanies the congestion. The urine is frequently 



ABSCESS OF THE LIVEE. 257 

deficient and concentrated, depositing abundant urates; it 
also may contain biliary coloring matter. 

The physical signs of congested liver are moderate enlarge- 
ment, liable to some variation ; regularity and uniformity in 
shape, in surface and margins ; with somewhat increased 
firmness. 

Treatment. — For active congestion the measures to be 
adopted are — to remove its exciting cause, an emetic being 
useful if it is due to irritating articles of food; to restrict the 
diet to small quantities of beef-tea, milk, and such articles ; 
to apply warm poultices, fomentations, or sinapisms over the 
hepatic region, dry-cup freely ; give a dose of podphillin 
followed by saline aperients, such as citrate of magnesia, 
sulphate with carbonate of magnesia, sulphate of soda, or 
cream of tartar. After the acute symptoms have subsided, 
alkalies with bitter tonics are useful, as well as alkaline and 
saline minerarwaters ; and subseqently the principles of treat- 
ment must be similar to those described hereafter in connec- 
tion with chronic hepatic diseases. These will also apply to 
cases of mechanical congestion. 

Circumscribed or Suppurative Inflammation — He- 
patic Abscess. 

Etiology and Pathology. — The usual form of acute 
inflammation of the liver-tissue ends in suppuration, which is 
rare, except in tropical climates. The cases in this country 
are principally among sailors and others who have come from 
these regions. We have two forms of hepatic abscess, the 
tropical and pycemic, the latter occurring in temperate climates. 

Causes. — 1. Direct injury to the liver, or over the hepatic 
region. 2. Convection of septic matters from various parts of 
the body, either internal or external, the products of wounds, 
operations, abscesses, ulcerations, gangrene, &c. The deleteri- 
ous substances may come from any part, but hepatic abscess 
is especially frequent after ulceration or gangrene of the 
stomach or bowels, as the result of operations affecting the 

20* 



258 ABSCESS OF THE LIVER. 

alimentary canal, and in connection with ulceration or sup- 
purative inflammation about the bile-ducts or gall-bladder, 
because then the materials are immediately taken up by the 
portal system of vessels. These cases may originate in 
phlebitis, extending along the portal vessels to the liver. 3. 
An embolus or thrombus in the portal vein softens and 
breaks down (suppurative pylephlebitis), and the particles 
may be conveyed into the liver and originate an abscess there. 
4. Rarely some direct irritation in the substance of the liver, 
as a suppurating hydatid cyst, gallstones, roundworms which 
have entered through the ducts, or foreign bodies. 5. The 
etiology of tropical abscess requires special comment. There 
are two views as to the exciting causes of the inflammation in 
these cases: 1. That it is the direct result of continued intense 
heat combined with malarial influence. 2. That in addition to 
these influences, which induce a predisposing depraved condi- 
tion of system, there must be a sudden chill. Intemperance, 
excessive eating, indolent and luxurious habits generally, act 
as powerful predisposing causes. 

Anatomical Characters. — The post-mortem examina- 
tion in acute hepatitis generally reveals suppuration. It is 
supposed to commence with active hyperemia, followed by 
effusion of lymph and degeneration of the hepatic cells, caus- 
ing the affected part to become swollen or prominent, paler, 
yellowish and softened; then suppuration begins in points in 
the centre of the lobules, which gradually coalesce, forming 
abscesses of various sizes. The pus-cells are probably partly 
leucocytes, partly the products of endogenous multiplication 
of the liver-cells. The situation, number, size, and exact 
shape of the abscesses vary widely, as well as the nature and 
amount of their contents, and the condition of the surround- 
ing tissue. The right lobe is much more frequently affected 
than the left. Important differences as. to number and size are 
observed between tropical and pycemic abscesses. In the for- 
mer case there is generally one large abscess, and rarely is the 
number above three; in the latter the separate accumulations 



ABSCESS OF THE LIVER. 259 

of pus are very numerous and small, not often being above a 
hen's egg in size. 

The progress and termination of these abscesses are variable. 
AVhen large, and especially of the tropical variety, they tend 
toward the surface or in some other direction, finally bursting 
externally, or into the peritoneum, intestines, stomach, gall- 
bladder, hepatic duct, hepatic or portal vein, inferior vena 
cava, pelvis of right kidney, or, rarely, through the diaphragm 
into the pleura, lung, or pericardium. After the discharge of 
the pus, cicatrization may take place, causing contraction and 
depression of the surface of the liver. In some cases an 
abscess remains dormant for a considerable period, and then 
rapidly increases. The fluid portion of the pus may be 
absorbed, the contents becoming caseous, then putty-like, and 
finally calcareous, the tissue around forming a dense cicatrix. 

The gall-bladder is sometimes inflamed. The bile in it is 
frequently unhealthy, but presents no special characters. The 
consequences of the rupture of an abscess into various struc- 
tures are elsewhere described. 

Symptoms. — Local. — Pain and tenderness are complained 
of over the hepatic region, often preceded by uneasiness. The 
pain differs much in its severity and characters; in most cases 
it is dull, aching, and tense, but usually increases as suppura- 
tion occurs, and may then become throbbing; it is more 
marked when the inflammation is near the surface. Sympa- 
thetic pains about the right shoulder and scapula are occasion- 
ally present, but only when the upper surface of the right 
lobe is affected. Then also a deep breath or cough aggravates 
the pain, and the breathing is hurried, short, chiefly upper 
costal, while there is some sense of dyspnoea, with often a 
short, dry cough. Jaundice is very uncommon in connection 
with tropical abscess, but some degree of it is observed in 
pysemic cases. Ascites is extremely rare, unless the inflam- 
mation depends on pylephlebitis, when signs of obstruction of 
the portal vein are prominent. More or less disturbance of 
the alimentary canal is almost always observed, such as loss 



260 ABSCESS OF THE LIVEB. 

of appetite, furred and irritable tongue ; thirst, nausea or 
vomiting, constipation or diarrhoea. The urine is at first very 
markedly febrile; after suppuration it often becomes pale, 
copious, and deficient in urea. 

Physical Characters. — The liver is at first uniformly and 
moderately enlarged. Should the abscesses formed be small 
and deeply seatecL as in pyemic cases, nothing further can be 
observed; but if one or more of them become large and super- 
ficial, then the following characters are presented: 1. The 
general enlargement increases considerably, and a bulging 
prominence presents in some direction, or occasionally more 
than one. This is generally observed in the epigastrium or 
right hypochondrium ; sometimes it causes distension of the 
lower part of the chest, with flattening of the spaces. 2. The 
general surface and margins of the liver, as a rule, feel smooth 
and regular, but occasionally from the projection of several 
small abscesses, or on account of perihepatitis, they are undu- 
lated and irregular. 3. The local bulging soon affords a 
sensation of elasticity, and then of fluctuation, gradually 
extending and becoming more perceptible, surrounded by a 
ring of inflammatory induration. There is no "hydatid 
fremitus." 4. The hepatic dullness is altered in outline as well 
as in area, and when the abscess tends towards the thorax, this 
is often one of the chief* signs noticed. 5. Auscultation may 
reveal friction-sound over an abscess, due to peritonitis. It 
may also indicate invasion of the qhest, and interference with 
the expansion of the lung. 6. By means of the exploratory 
trocar pus may be obtained, and this is important for diagnosis 
in doubtful cases. Harked pulsation may be observed in 
connection with an abscess presenting in the epigastrium, 
conducted from the aorta, and simulating aneurism. The 
spleen may be enlarged, but chiefly in pyemic cases, and not 
as the direct result of the hepatic disease. 

General Symptoms. — Chills or rigors often usher in an 
attack of acute hepatitis, followed by more or less pyrexia and 
considerable constitutional disturbance. Suppuration is indi- 



PERIHEPATITIS. 261 

cated by repeated rigors, fever of a hectic type, remittent or 
intermittent, with sweats, prostration and wasting. Ultimate- 
ly typhoid symptoms may occur, ending in low nervous 
disturbance and death. 

The ultimate course of events will depend upon the progress 
of the disease. The symptoms may subside, and the abscess 
undergo retrograde changes, ending in cure. Almost always, 
however, it tends to open in some of the directions already 
mentioned, and the corresponding symptoms will be readily 
understood. When it approaches the surface, it produces 
redness, oedema, and other signs of superficial suppuration, 
before it bursts. Most cases of hepatic abscess are rapid in 
their progress, but tropical cases may last six months or more; 
pysemic forms are much the more fatal and speedy in their 
termination. Some cases go on for a long period, and ulti- 
mately recover, the abscess discharging its contents and 
cicatrizing. 

II. Perihepatitis. 

This term is applied to inflammation of the covering of the 
liver and Glisson's capsule, which is not uncommon as an 
acute affection, associated with peritonitis, or organic diseases 
of the liver, or resulting from injury or extension of inflam- 
mation from neighboring parts. It may arise from a chill. 
It tends to exudation, with thickening, opacity, and adhesions; 
occasionally pus is formed. The symptoms are pain, some- 
times sharp, increased by cough and deep breathing, with 
superficial tenderness, but no particular derangement of the 
hepatic functions, or alterations in the physical characters of 
the liver. There is usually more or less fever. If it is 
chronic, or if there are repeated attacks, as not uncommonly 
happens in syphilis or chronic heart diseases, there may be 
signs of obstruction of the portal vein or bile-duct, with 
atrophy of the liver. 

III. Inflammation of the Bile-Ducts. 
Catarrh of the bile-ducts is a common' affection, especially 



262 INFLAMMATION OF THE BILE-DUCTS. 

r 

in children and old gouty persons. Its chief causes are 
extension of catarrh from the duodenum; hepatic congestion ; 
irritation of the mucous membrane by gallstones, parasites, 
foreign bodies, unhealthy bile, causing considerable inflam- 
mation ; and blood-poisoning in fevers and other affections. 
The morbid appearances are similar to those of other catarrhs. 
Occasionally croupous or diphtheritic inflammation is 
observed. The symptoms of simple catarrh indicate partial 
obstruction of the bile-ducts, with jaundice, enlargement of 
the liver and gall-bladder, preceded by signs of gastro- 
duodenal catarrh. Often local pain and tenderness, with some 
fever. The duration and course of these cases vary much. 

Diagnosis. — At first there may be considerable difficulty 
in distinguishing inflammation from mere active congestion, 
and also in separating the different kinds of inflammation 
from each other, especially suppurative hepatitis and peri- 
hepatitis. When pus forms, this is generally revealed by 
evident physical signs and increased constitutional disturb- 
ance. Commonly, however, distinct objective indications of 
pysemic abscesses are wanting; the differences between these 
and tropical abscess have been mentioned. The conditions 
which, may be mistaken for abscess in the liver are inflamma- 
tion and suppuration in the gall-bladder, a suppurating 
hydatid cyst, and abscess in the abdominal parietes. 

Prognosis. — In the milder forms of hepatic inflammation 
the prognosis is favorable, but when suppuration occurs it is 
very serious. It will then depend mainly on the size and 
probable number of the abscesses ; the direction in which they 
open (Maclean stating as his experience that the largest num- 
ber of recoveries follows bursting into the lung, and then into 
the intestine ; and that the prognosis is much more favorable 
when the abscess points at the ensiform cartilage than in an 
intercostal space); the general condition of the patient; and 
whether the liver-affection is associated with other morbid 
states, such as dysentery. Pyemic abscesses are very fatal. 



ABSCESS OF THE LIVER. 263 

Treatment. — The slighter forms may be treated in the 
manner described under congestion. Much difference of 
opinion is held as to the management of tropical abscess in its 
early stage. The usual measures are emetics; cupping; con- 
stant poulticing or fomentations; saline purgatives; and the 
administration of ipecacuanha, as in dysentery. In pysemic 
abscess, lowering measures are injurious. When suppuration 
occurs, poultices and fomentations must be assiduously applied. 
The question of opening abscesses is much discussed. Most 
authorities seem to favor operating; some prefer leaving the 
abscess to take its own course, on account of the dangers of 
peritonitis, decomposition from entrance of air, hemorrhage, 
or gangrene. If there is satisfactory evidence of the existence 
of a single" abscess, it appears advisable to let the matter out, 
and even in doubtful cases a small exploratory trocar may be 
employed. When there are several collections of pus, as in 
pyaemia, operative interference is contraindicated. The differ- 
ent modes of evacuation are by puncture with a small trocar 
and canula ; free incision ; or application of caustic potash so 
as to produce a slough, this last being also used to excite 
adhesions to the abdominal wall. The air must be excluded 
and carbolic acid freely used. In the case of a moderate- 
sized abscess, it seems best to let out all the pus at once, and 
leave a drainage-tube in ; when very large, it may be emptied 
gradually by successive operations. Large poultices should 
be afterwards applied, frequently changed, and disinfectants 
freely used, the patient lying as much as possible in that 
position most favorable for the escape of the pus. It is use- 
ful in some cases to wash out the abscess with weak carbolic 
acid. In the early period of the disease the diet should con- 
sist of milk, beef tea, &c; when suppuration is set up it should 
be as nourishing as possible, while stimulants are called for at 
this time, as also quinine, mineral acids, or tincture of steel. 
Narcotics are often required, and various symptoms demand 
attention in many cases. The general treatment for pyaemia 
is indicated in pysemic cases. 



264 Atftfffi YELL6W ATROPHY. 

Acute Yellow Atrophy. 

Etiology and Pathology. — The causation of this rare 
disease is very uncertain. Most cases occur in connection 
with pregnancy, but it has also been attributed to severe 
nervous disturbance due to depressing emotions ; blood-poison- 
ing in typhus, scarlatina, &c. ; malarial influence ; or to the 
production within the body of some special poison as the result 
of faulty digestion or assimilation. The chief predisposing 
causes mentioned are age, the disease almost always being 
observed before 40, but never in childhood ; the female sex ; 
intemperance ; venereal excesses ; and syphilis. 

Most authorities consider acute atrophy as being the result 
of diffuse parenchymatous inflammation excited by some poison. 
It has also been attributed to obstruction of the smaller bile- 
ducts, or to excessive collection of bile in them, by pressure 
upon the surrounding structures. 

Anatomical Characters. — Diminution in size and weight 
of the liver, relaxation of tissue and softening, change in color 
to a dull yellow, and disappearance of any lobular divisions. 
It may be reduced to half its ordinary bulk, or less, being 
especially diminished in thickness, and it lies back out of 
sight, shrunken and flaccid, while the peritoneum covering it 
is lax and often in folds. In parts where the disease is less 
advanced hyperemia and a grayish exudation have been 
described. Microscopic examination reveals fatty degenera- 
tion and destruction of the gland-cells, until nothing remains 
but a granular detritis, oil-globules, and pigment. There is 
only a little mucus in the gall-bladder and ducts as a rule. 
Extravasations of blood in the alimentary canal and other 
parts, with ecchymoses, are common. The spleen is generally 
enlarged. The kidneys exhibit degeneration of, and deposits 
of pigment in, the epithelium cells. Leucin and tyrosin are 
found in the blood and tissues of the liver, spleen, and 
kidneys. 

Symptoms. — Slight jaundice is usually observed soon. It 
afterwards increases, but seldom becomes intense, and it may 



ACtfTE YELLOW ATROPHY. 266 

be iimited to the upper part of the body. This has been attri- 
buted to blocking-up of the smaller ducts by the debris of the 
cells. Among the usual symptoms are pain over the epigas- 
trium and hypochondriuni, with tenderness, vomiting, and 
constipation. There is not much pyrexia, but the pulse is 
often hurried and is liable to much variation, while the tem- 
perature is raised in some cases considerably towards the 
close. 

The striking clinical phenomina are those of the " typhoid 
state," with prominent nervous symptoms ; great diminution 
or complete disappearance of the hepatic dullness ; generally 
enlargement of the spleen ; peculiar changes in the urine; and 
hemorrhages. The nervous symptoms are at first headache, 
great depression, languor, irritability, and restlessness, speedily 
followed by low delirium, stupor, coma, twitchings, convul- 
sions, with involuntary discharge of faeces and urine. The 
tongue becomes brown and dry, with sordes on the teeth. 
The urine yields considerable quantities of leucin and tyrosin, 
w T hile the urea, uric acid, and salts are much diminished, some- 
times almost entirely absent; some bile-pigment is usually 
present, and often a little albumen or blood. Hemorrhage 
most frequently takes place into the stomach and bowels; 
cutaneous petechia? and vibices are not uncommon, and, in 
rare instances, uterine hemorrhage or epistaxis occurs. The 
course of the disease is generally very rapid, and the termina- 
tion fatal. When it arises in the course of pregnancy, it leads 
to miscarriage or abortion. 

Diagnosis. — At first it is difficult to diagnose acute 
atrophy, but once the symptoms are fully developed, with 
the physical signs of diminution in the size of the liver, 
the nature of the case becomes evident. 

Prognosis is very grave, the disease almost always ending 
fatally. 

Treatment. — Free purgation, promotion of the action of 
the skin by hot air or vapor baths, diuretics, cold douches to 
the head, have been the chief measures recommended, but 



266 HYPERTROPHY AND ATROPHY. 

they are of little service when the disease is established. 
Hemorrhages and other symptoms must be treated as they 
arise, with supporting and soothing measures generally. 

CHRONIC DISEASES OF THE LIVER. 

HYPERTROPHY AND ATROPHY. 

A simple hypertrophy of the hepatic tissue is observed in 
some cases of leucocythaBmia, very rarely in diabetes, and as 
the result of residence in hot climates. Clinically it is'indi- 
cated by a slow^ moderate, and uniform enlargement of the 
liver, without any evident symptoms. 

Atrophy generally occurs in old age, and may result from 
starvation, or pressure upon the surface of the organ by tight 
stays, peritoneal adhesions, &c. 

Fatty Liver — Hepar Adiposum. 

Etiology. — This belongs to the fatty infiltrations, the 
secreting cells becoming filled with oil. The conditions are : 
1. In phthisis and other wasting diseases, such as ^cancer, 
gastric ulcer, chronic dysentery. 2. In chronic lung and 
heart affections, leading to imperfect aeration of blood. 3. As 
the result of over-feeding, especially excessive consumption of 
hydrocarbonaceous substances, and abuse of alcohol in the 
form of ardent spirits. Deficient exercise and indolent habits 
aid the development of the disease. Some individuals are 
more predisposed than others. Fatty degeneration may be set 
up in connection with other morbid conditions of the liver, 
as albuminoid infiltration or cirrhosis. 

Anatomical Characters. — Enlargement and increase in 
weight, though the specific gravity is diminished, the margins 
thickened and rounded, and the surface quite smooth ; yellow- 
ish color with opacity, both externally and on section, mottled 
with red softening of the tissue, has a doughy, inelastic feel, 



FATTY LIVER — ALBUMINOID LIVER. 267 

pits on pressure, and readily breaks down or tears ; ansemia, 
but little blood escaping from the cut surface ; loss of distinct- 
ness of outline of the lobules ; and evidence of the presence of 
much fat to the knife, blotting-paper, or ether. The liver 
may yield as much as 43 or 45 per cent, of oily matters, which 
consist of olein and margarin, with traces of cholesterin. 
Microscopic examination shows enlargement of the cells, 
which are spherical, and loaded with fat. In the less 
advanced cases this reveals the change. The morbid process 
extends from the circumference of the lobules towards the 
centre. 

Symptoms. — Dyspeptic disturbances are common. Physi- 
cal examination is the only positive means of diagnosing fatty 
liver: 1. There is enlargement in a downward direction, 
slow in its progress, and usually moderate in degree, the organ 
never attaining any great size. 2. The shape is quite normal, 
and the surface and margins are smooth and regular, the latter 
feeling rounded. 3. Palpation' often reveals a soft, doughy 
consistence of the tissue. The general symptoms are those 
associated with fatty changes, viz., want of tone, inaptitude 
for exertion, pallor and pastiness of the skin, &c. Signs of 
fatty changes in other organs and tissues, as the heart, vessels, 
and kidneys, may be observed. 

Albuminoid, Lardaceous, or Waxy Liver. 

For the etiology and pathology of this morbid condition 
the reader is referred to the chapter which treats of it 
generally. The liver is one of the most common seats of 
albuminoid deposit. 

Anatomical Characters. — The size and weight are con- 
siderably increased, and the specific gravity. The liver is 
somewhat flattened, with rounded edges. The surface and 
margins are quite smooth, the peritoneum stretched, and the 
tissue feels very firm and resistant. On section the usual 
pale, anaemic, dry, grayish, and glistening aspect of larda- 
ceous disease is observed; the surface is quite homogeneous, 



26S HYDATID TUMOK OF THE LIVER. 

without any trace of lobules, or these may appear enlarged. 
The ordinary chemical tests are yielded, and microscopic 
examination reveals the presence of the deposit in connec- 
tion with the vessels and cells. It is first observed in the 
middle zone of the lobules, where the branches of the 
hepatic artery are distributed. The exact appearances may be 
varied by the association of other morbid conditions, such 
as fatty degeneration, cirrhosis, or syphilitic cicatrices. The 
disease commonly involves other organs. 

Symptoms. — A feeling of weight, tension, and discomfort. 
Jaundice and signs of obstruction of the circulation when 
present are due to pressure by enlarged glands in the 
portal fissure, or thickenings with local inflammatory 
changes; or, ascites, to chronic peritonitis or constitutional 
debiiity and ansemia. The physical signs are : 1. Enlarge- 
ment in a downward direction, gradual in its progress, fre- 
quently very great at last, so as to present a visible, prom- 
inent tumor. 2. No alteration in form, the surface smooth 
and uniform, with rounding of the margin. 3. Consist- 
ence dense and resistant, often hard. These are the usual 
general symptoms indicative of albuminoid disease, with 
signs of implication of other organs, and the existence of 
some constitutional condition associated with it. 

Hydatid Tumor of the Liver— Echinococcus Homlnis 
acephalocyst. 

Etiology and Pathology. — The morbid condition, re- 
sulting from the development of the embryo of a tape- 
worm in the human body, is afforded by this complaint, 
though the parasite may be found in almost every organ and 
tissue in the body, yet the liver is its most frequent seat, the 
subject may be treated once for all in the present chapter. A 
hydatid tumor is due to the development of embryos of the 
tcenia echinococcus, each of which produces a scolex, named 
echinocoecus hominis, and then they become inclosed in cysts. 
This tapeworm infests dogs and wolves, fragments are evacu- 
ated in the excreta, their ova are set free, become mixed with 



HYDATID TUMOR OF THE LIVER. 269 

water or food, and are thus introduced into the alimentary 
canal of a human being. When the embryos are liberated 
they bore the walls with their hooks, and then migrate, 
usually settling in the liver, there developing into scolices. 
The echinococcus also infest sheep, and mutton-eating dogs 
become the seat of the tapeworm. 

In Iceland this disease is especially prevalent. In this part 
of the world it is exceptionally met with, usually those who 
have been abroad. Most cases occur during middle life, and 
among the poorer classes. 

Anatomical Characte&s. — The structures which ordi- 
narily form a typical hydatid tumor, are: 1. Externally a 
firm, whitish or yellowish, fibrous vascular capsule adherent 
to the surrounding tissues. 2. Within this, moulded to its 
interior but easily separated from it, is a delicate cyst or 
bladder, elastic, grayish, semi-transparent or gelatinous in 
aspect, and compared to boiled white of egg ; under the micro- 
scope it is seen to consist of several hyaline, concentric layers, 
a section presenting a characteristic laminated appearance. 
The most internal layer is extremly delicate and studded with 
minute transparent cells. The term " mother-sac or vesicle," 
is usually applied to this structure as a whole ; but it has also 
been limited to the internal lamina just mentioned, which has 
been termed the " germinal membrane." 3. A quantity of 
fluid is contained within this cyst, usually completely filling 
it, colorless and transparent ; of low specific gravity ( 1007 to 
1009); generally alkaline or neutral, but may be acid ; and 
consisting mainly of a strong solution of chloride of sodium, 
without any albumen or other organic substance. 4. Floating 
in this fluid, or attached to the inner surface of this mother- 
cyst when small, are numerous secondary or "daughter cysts," 
in some instances amounting to hundreds or thousands, 
completely filling the space so that there is little or no fluid, 
and becoming flattened by mutual pressure, having precisely 
the same structure as the mother-sac ; within the larger of 
these there may be a third generation, and rarely a fourth. 



270 HYDATID TUMOR OF THE LIVER. 

5. When the walls of the sacs are examined carefully, little 
whitish, opaque spots are visible on the inner surface, which 
are the scolices of the echinococcus in various stages of devel- 
opment, usually in groups or clusters, occasionally single. 
These may also be free in the fluid, making it somewhat 
opaque. Each scolex is very minute, measuring from l-20th 
to l-6th of a line in length, but this and the form vary 
according as the head is retracted into the body or extended. 
The head presents a proboscis, four suckers, with a double 
circle of characteristic, curved hooks, movable, of unequal 
length ; a constriction separates it from the body, the latter 
being striated longitudinally and transversely, presenting 
behind a depression with a pedicle, by which the animal 
is fixed to the sac in its early condition. Numerous round 
and oval calcareous particles are imbedded in the tissue. 

In most cases there is but one tumor, sometimes two, 
three, or more, one predominating over the others. The 
size varies extremely; the hydatid may attain dimensions to 
fill the abdomen and invade the chest. The daughter-cysts, 
range from a millet-seed to an egg in size; subsequent gen- 
erations are very minute. The right lobe is the most frequent 
seat, but the cyst may be in any part, deep or superficial. 
Necessarily if the hydatids are numerous, large, or super- 
ficial, they alter the dimensions and form of the liver. 
The surrounding hepatic tissue is atrophied; sometimes 
hypertrophy of the healthy portion. Peritonitis may be 
excited over the tumor, causing thickening and adhesions. 

In the course of hydatid disease, 1. The tumor enlarges, 
displacing adjoining structures and interfering with their 
functions, until it bursts in some direction, or is ruptured 
by violence or in some other way. The opening may occur 
externally through the abdominal or lower thoracic walls ; 
into the pleura or lung, especially the right, which is the 
most common direction ; pericardium rarely, peritoneum, 
stomach or intestines," gall-bladder or bile-duets, hepatic 
vein or inferior vena cava. 2. Inflammation and suppura- 



HYDATID TUMOR OF THE LIVER. 271 

:ion sometimes occur, either spontaneously from rapid growth, 
Torn injury or operation, or from the entrance of bile. 3. 
[f the hydatid is slow in its progress, it not uncommonly 
mdergoes degenerative processes as it gets older, and this 
nay ultimately bring about a spontaneous cure. The en- 
rance of bile is supposed sometimes to induce this. The 
niter capsule becomes much ' thickened, firm, irregular, 
>paque, and ultimately calcined partially or completely. This 
mpedes further growth, and the contained hydatids com- 
)ress each other, shrivel, and die. The fluid thickens, 
atty and calcareous degeneration takes place, until there 
>nly remains a putty-like debris, in which shreds of the 
resides and hooklets of the echinococci are embedded, re- 
pealing the nature of the mass. A cicatrix-like depression 
nay finally be left. 4. Occasionally cysts are found in 
vhich there are no echinococci. The name " acephalocyst " 
las been applied to this condition, and it has been regarded 
& an abortive or sterile form of the parasite, in which 
he development is arrested. 

A very rare form of this disease is named " Multilocular 
lydatid cyst." The liver is occupied by a mass, in some 
:ases as large as a child's head, or larger, consisting of a 
troma of cellular tissue, usually altered by fatty degeneration, 
n which are imbedded cells or alveoli of various sizes, inclos- 
ng a gelatinous substance, in which microscopic examination 
eveals fragments of the laminated membrane of hydatids, 
looklets, or even perfect scolices and calcareous particles. 
Che centre of this mass is liable to undergo suppuration, alter- 
ng its characters. This has been attributed to the embryos 
laving been deposited in the lymphatics, bloodvessels, or 
lucts of the liver; or to the absence of early rupture of the 
xternal fibrous cyst, so that the parasites grow and migrate 
n various directions, and thus enter the different vessels. 

Symptoms. — It may be latent from first to last. Should it 
,ttain a great size, there is a sense of fullness and tension, in 
are cases jaundice, or signs of portal obstruction, in oonse- 



272 HYDATID TUMOR OF THE LIVER. 

quence of pressure upon the ducts or veins, or their being 
blocked up by hydatids. Surrounding structures may also be 
interfered with, especially the diaphragm and respiratory 
organs. Should the cyst rupture, the symptoms depend on 
the direction in which this occurs, being in many instances 
very grave. If the opening is external, characteristic struc- 
tures may be discharged. The occurrence of suppuration is 
indicated by the ordinary local and constitutional signs of 
hepatic abscess. 

The physical characters of hydatid tumors demand particular 
attention. 1. The liver is enlarged, and this is the first to 
attract notice. The growth is chronic and imperceptible, but 
it may attain enormous dimensions, so as to give rise to a 
general enlargement of the abdomen, or it may invade the 
whole of the chest, causing it to bulge. 2. The form of the 
liver is altered, as evidenced by palpation and percussion; 
there is an evident tumor in some part, especially the epigas- 
trium or hypochondrium. Smaller prominences are some- 
times felt along the margins or surface, causing lobulation 
and irregularity. 3. Any prominent hydatid tumor is gener- 
ally quite smooth, and more or less elastic or fluctuating. 4. 
" Hydatid fremitus" is often elicited very clearly. 5. In any 
doubtful case it is justifiable to make an exploratory puncture 
with a small trocar and remove some of the fluid, the physical 
and chemical characters of which are quite characteristic. 
Perhaps some of the microscopic structures may come away. 

The signs described are modified by the degenerative and 
other changes which occur in the cyst. The outer wall mav 
feel hard and bony. If the case comes under observation 
when the abdomen presents a general enlargement, it is not 
easy, except by the history, to make out where the growth 
originated. 

The mutilocular cyst is said to be distinguished by being 
nodulated, hard and tender; by jaundice, ascites, and enlarge- 
ment of the spleen being usually present ; and by its tendency 
to inflame and suppurate. This may run a rapid course. 



cancerous and other growths. 273 

Cancerous and Other Growths of the Liver. 

Etiology. — The liver is a frequent seat of internal cancer, 
either primary or secondary, the latter occurring after cancer of 
the stomach. It has been attributed to injury. Most cases 
are between 50 and 70 years of age, the disease being extremely 
rare before adult life. In some there is an hereditary taint. 
It is more common among males. 

Anatomical Characters. — Hepatic cancer occurs in the 
form of tuberous masses, intermediate between those of 
scirrhus and encephaloid, approaching more to one variety or 
the other in different instances. There is a wide difference in 
size and number, the nodules being small at first, and gradu- 
ally enlarging, until they may reach the dimensions of a 
child's head or more. Several are found, unequal in size, and 
by their coalescence considerable tracts of the organ are some- 
times involved. Originally the shape is spherical, but when 
the masses reach the surface they become flattened, or 
depressed in the centre, so as to present shallow concavities or 
umbilications. They are not separated from the surrounding 
tissue by any definite structure, but occasionally there is a 
distinct cyst around a mass. The consistence is moderately 
firm, but it may range from that of a soft, brain-like, semi- 
fluctuating substance to that of a hard, cartilaginous tissue, 
and the amount of cancer-juice which can be expressed will 
vary accordingly. The color of a section is mostly white or 
yellowish-white, dotted and streaked with red, from vessels, 
but may be extremely vascular and dark-red, resembling 
"fungus nematodes." The proportion of cancer-cells and 
fibrous stroma in any mass, as observed under the microscope, 
depends on the variety. 

The liver is enlarged in proportion to the number and size 
of the growths, being often large and heavy and irregular. 
Its tissues are more or less destroyed and compressed, the ves- 
sels and ducts are invaded or obliterated, jaundice and signs of 
obstructed circulation are often the result present. New 
vessels form from the hepatic artery. The cancer begins in 

21* 



274 CANCEROUS AND OTHER GROWTHS. 

the centre of the lobules or the interlobular tissue. When a 
mass reaches the surface it produces limited peritonitis, with 
thickening and adhesions. Neighboring tissues are involved 
by extension, and the Lymphatic glands in the portal fissure. 

The growth is rapid when the cancer is soft. Certain 
changes are liable to occur. The vessels of encephaloid cancer 
often give way, leading to extravasations of blood into tne in- 
terior, which afterward change, and cause unusual appearances. 
Very soft accumulations have burst into the peritoneum in 
rare instances. Degenerative changes frequently occur in the 
less rapid forms, in the way of caseation, or atrophy with con- 
traction, induration, and the formation of a firm cicatrix. A 
section often presents a reticulated appearance from fatty 
degeneration. 

Exceptionally hepatic cancer is infiltrated. Melanosis, 
cystic cancer, and colloid have been rarely met with. Recent 
careful observation has shown that some of the morbid growths, 
described as cancer, are composed of spindle-celled sarcoma ; 
cysts, resulting from obstructed ducts, and erectile tumors 
have been described. 

Symptoms. — Hepatic cancer is characterized by marked 
local disturbances; it may be latent. At first, a sense of dis- 
comfort and weight soon increasing to distinct pain and 
tenderness, often very severe, especially if the growth of the 
cancer is rapid, or if peritonitis is excited. The pain is often 
lancinating, shooting to the back, shoulders, over the abdomen, 
&c. Jaundice and ascites are common symptoms, the result of 
obstruction of the main ducts and vessels by projections from 
the liver or glands in the fissure; ascites may be associated 
with chronic peritonitis. Once the jaundice begins it is per- 
sistent, often intense; it may be temporary from catarrh of 
the ducts. The spleen is rarely enlarged. The superficial 
abdominal veins are sometimes distended. 

Physical Signs. — The liver signs indicative of cancer are : 
1. Enlargement, often great, rapid in its progress, and chiefly 
in a downward direction. 2. Alteration in shape and irregu- 



CIRRHOSIS OF THE LIVER — CHRONIC ATROPHY. 275 

larity of outline, nodules or larger masses being felt, some- 
times seen along the surface and margins, which are common- 
ly u nib Weeded. 3. Firmness and resistance of the projections, 
occasionally a soft elastic feel, or a sense of obscure fluctuation. 
4. Occasionally, friction-fremitus and sound during breathing, 
these being due to peritonitis. 

Digestive derangements are present in most cases, and first 
attract attention. The cancerous cachexia is well-marked, 
with rapid wasting, debility, and anseinia. The pyrexia is 
sometimes considerable when the progress of the disease is 
rapid. Cancer often occurs in other organs, either primary or 
secondary. 

The progress of hepatic cancer is generally rapid, and 
rarely extends beyond a year. 

Cirrhosis of the Liver — Chronic Atrophy. 

Etiology and Pathology. — Several distinct morbid 
conditions have been included under the term " cirrhosis," 
which have different modes of origin. The genuine disease 
results from a chronic interstitial inflammation, extending into 
the minutest portal canals, and leading to proliferation of 
cellular tissue between the lobules, or to an exudation, 
which organizes and then contracts, with pressure upon and 
obliteration of the vessels, and atrophy of the secreting 
elements. Some attribute it to a constitutional diathesis 
characterized by the formation of a fibroid tissue in different 
structures of the body, of which the morbid state of the 
liver is a local development. Others regard the disease as 
commencing in degeneration and destruction of the secreting 
cells, the ducts, vessels, and areolar tissue remaining, fol- 
lowed or not by proliferation of the latter. The important 
exciting cause of these changes is abuse of alcohol, especially 
indulgence in ardent spirits on an empty stomach. Hence, 
the common name " gin-drinker's liver." The alcohol being 
absorbed and circulating through the liver either sets up 
inflammation or leads to degeneration of the cells. Cirrho- 



276 CIEEHOSIS OF THE LIVES — CHEOXIC ATEOPHY. 

sis occurs without intemperance, and is then attributed to 
malaria or prolonged heat, abuse of hot condiments and 
various articles of diet, the circulation of products of 
faulty digestion, or to the extension of a localized 
peritoneal inflammation. It occurs between 30 and 50 years 
of age, being rare in youth, and not common in advanced 
age. Males suffer more than females, and those whose 
occupation exposes them to the exciting cause. 

Anatomical Chaeacters. — In the advanced stage of 
cirrhosis the liver is wasted, and diminished in weight, some- 
times even § or J-, especially the left lobe and edges, the 
latter being often reduced to a thin fibrous rim. The form 
is rounded. The surface is pale and covered with roundish 
prominences, varying in size from minute granules to pro- 
jections or knobs J or \ an inch in diameter, or larger, 
like hobnails (hence the names " granular or hobnailed 
liver "). They may be uniform in size, but are commonly 
unequal. Local depressions are frequent. The capsule is 
thickened, inseparable; local peritoneal adhesions and 
thickenings are constant. The consistence is dense, firm, 
tough, and leathery. The color is a mixture of grayish and 
yellow ; the former arranged in bands of different widths, 
sometimes extending over considerable tracts; the latter varies 
in tint, in some specimens bright-yellow, in others almost 
brownish, corresponding to the granulations. The name 
"cirrhosis " is derived from its yellow appearance. 

The effects of cirrhosis outside the liver are important, visi- 
ble on post-mortem, being mainly those from obstruction of 
the portal circulation. Most important as to treatment is the 
fact that considerable anastomoses form between the hemor- 
rhoidal veins, and the superficial branches of the portal vein 
in the liver and the veins of the diaphragm and abdominal 
walls; through the peritoneal adhesions and along the sus- 
pensory ligament. 

Similar changes to those observed in cirrhosis are not un- 
frequent in other organs and tissues at the same time. 



CIRRHOSIS OF THE LIVER — CHROMIC ATROPHY. 277 

Other forms of chronic atrophy : 1. The result of long- 
continued mechanical congestion from heart disease, the liver 
contracts and presents characters much resembling those -of 
true cirrhosis, with an important difference, and the atrophy 
is rarely so marked as in the latter. It is produced by the 
pressure of the distended tributaries of the hepatic vein upon 
the contiguous cells, causing their degeneration ; hence the 
centre of the lobules becomes first wasted and depressed; the 
circumference remains and forms granulations. Ultimately 
extensive depressions are produced, and proliferation of con- 
nective tissue occurs. Attacks of chronic perihepatitis are 
common, increasing the tendency to atrophy. 

2. A form of granular atrophy, independent of intemper- 
ance; the fibrous tissue is not increased, and the liver is softer 
than in health. 

3. Atrophy may result from adhesive pylephelbitis : the 
trunk or some of the branches of the portal vein are obliter- 
ated. Cicatricial retractions are observed on the surface, with 
corresponding indurations. 

4. A form due to chronic attacks of perihepatitis : thick- 
ening of the capsule or pressure upon the vessels ; fibrous 
bands pass into the interior, but no granulated appearance. 

5. Syphilis commonly leads to atrophy, by exciting peri- 
hepatitis or simple interstitial hepatitis, or as the result of 
changes in gummatous deposits. 

6. The last variety is named "red or chronic atrophy." 
It may be associated with the deposit of pigment in the 
minute vessels, especially after prolonged and repeated 
attacks of malarial fever; it sometimes follows ulceration in 
the alimentary canal. The entire organ is wasted, but it 
differs from true cirrhosis, there being no granulation of the 
surface ; in a section being dark-brown or bluish-red and 
homogeneous, being little indication of lobules ; the consist- 
ence being less firm. The cells are diminished, filled with 
brown pigment-granules. The ramifications of the portal 
a gallstone, but to its angular shape. It usually diminishes when 



278 CHROKIC ATROPHY. 

vein are destroyed, its branches ending in csecal, club-shaped 
extremities. 

Symptoms. — In all these forms of contracted liver, the 
diagnostic clinical indications are derived from the evidences 
of interference with the 'portal circulation, and the signs afforded 
by physical examination. There are additional symptoms due 
to derangement of the secreting functions, and others evidencing 
marked constitutional disturbance. 

In the early stage of true cirrhosis it is customary to find a 
train of symptoms merely of congestion of the liver with 
gastroenteric catarrh, due to abuse of alcohol; there is nothing 
characteristic about them. Occasionally the disease begins 
with severe local symptoms, indicating acute hepatic conges- 
tion, catarrh of the ducts, and gastroenteritis, accompanied 
with fever. For a time there are evidences of enlargement of 
the liver. As the case advances the results of portal obstruc- 
tion are observed; ascites, often extreme ; enlargement of the 
superficial veins of the abdomen, especially on the right side ; 
gastroenteric catarrh ; hemorrhage from the stomach or 
intestines ; hemorrhoids ; and enlargement of the spleen. 
Digestive disturbances are prominent. Painful sensations 
about the hepatic region are present in the early stages; when 
the disease is advanced there is rarely uneasiness, if any ; 
there may be tenderness, due to peritonitis or perihepatitis. 
Jaundice is but rarely prominent; it is observed at the early 
period, mainly due to congestion, catarrh of the ducts, or 
pressure of enlarged glands. Extreme jaundice may result 
from perihepatitis, or it appears toward the termination of a 
case, independently of any obstruction. The stools usually 
contain bile. 

Physical Signs. — These are : 1. Diminution in hepatic 
dullness in proportion to the contraction. 2. Granulation or 
nodulation of the surface, with hardness. Sometimes the edge 
of the liver can be grasped between the thumb and fingers. 
3. Occasionally friction-sound. Ascites obscures the examina- 
tion, but the organ can be easily felt after paracentesis. In 



TUBERCULOSIS — SYPHILITIC DISEASE. 279 

some instances there is great enlargement of the liver, but the 
nodulated surface can be recognized. 

The constitutional disturbance is marked at last by emacia- 
tion and weakness, with a peculiar, sallow, earthy complexion, 
dry, harsh skim and flabby tissues. Purpuric spots and 
blotches on the skin may be visible, and there may be exten- 
sive ecchymoses or hemorrhages from mucous surfaces. 

The progress of cirrhosis is chronic, but may run a rapid 
course from its first appearance. The modes of death are 
gradual asthenia and exhaustion ; jaundice with typhoid 
symptoms ; lung complications ; acute peritonitis ; or hemor- 
rhage from the alimentary canal. 

Tuberculosis. 

Tubercle is observed in the liver in connection with general 
acute miliary tuberculosis. Occasionally it is secondary to 
chronic tubercle in other parts. It may break down and 
form small cavities. Clinically it cannot be recognized with 
any certainty. The organ is usually enlarged, it may be 
enormously. In post-mortem of J. Going, D. D., of Gran- 
ville, Ohio, I found his liver weighed fifteen pounds. 

Syphilitic Disease. 

The morbid conditions of the liver which may result from 
syphilis are : 1. Lardaceous disease. 2. Perihepatitis. 3. 
Simple interstitial hepatitis, leading to general atrophy and 
induration. 4. Gummous hepatitis, in which gummata are 
deposited extensively, undergoing degenerative changes and 
becoming surrounded by a dense fibroid tissue, from which 
processes extend toward the surface in various directions 
The liver tissue is destroyed, and deep cicatricial depressions 
or furrows are seen on the surface, producing a lobulated 
appearance. During life the characters of the liver may be 
determined by physical examination, in the gummatous form 
it is enlarged. There is pain, with tenderness, and signs of 



280 ' DISEASES OF THE GALL-BLADDER. 

obstruction of the bile-ducts and portal vein. The progress 
is usually chronic. 



CHAPTER Y. 

DISEASES OF THE GALL-BLADDER. 

The morbid conditions of the gall-bladder may be briefly 
stated. Most of them cause enlargement, and it is impor- 
tant to be able to recognize the distinctive clinical charac- 
ters of each form of enlargement. 

1. Distention with Bile. — When anything obstructs the 
commom bile-duct, as a gallstone, the gall-bladder becomes 
filled with bile and may attain enormous dimensions There 
will be the usual signs of obstructive jaundice, with enlarge- 
ment of the liver ; the gall-bladder is perceptible as a fluct- 
uating tumor, sometimes reaching nearly to the iliac crest, 
and somewhat tender. 

2. Acute Inflammation and Suppuration. — The mucous 
membrane is liable to catarrh, croupous or diphtheritic in- 
flammation; the important form of acute inflammation is 
that which is attended with pus in its interior, which re- 
sults from irritation of gallstones, or from obstruction of 
the cystic duct by these. It is indicated by a painful and 
tender fluctuating enlargement of the gall-bladder, which 
may assume the characters of an abscess, or even burst, 
accompanied with rigors and fever, the latter tending to a 
hectic type. It is preceded by signs of gallstones, but 
there in no jaundice or hepatic enlargement. 

3. Chronic Inflammation. Hydrops Vesicce Felleoz. Dropsy 
of the Gall-Bladder. — If the cystic duct is obstructed for a 
long period, the gall-bladder may gradually dilate by the 



DISEASES OF THE GALL-BLADDER. 281 

accumulation of a clear, serous, or synovial-like fluid; the 
walls become thinned and atrophied. The organ is dis- 
tended; often to an extreme degree; there is little pain or 
fever, jaundice is absent and the liver is not enlarged. 
Occasionally the result is different. The liquid portions of 
the contents of the gall-bladder are absorbed, an inspissated 
substance remains, in which calcareous salts are deposited ; 
the walls thicken and contract from chronic inflammation, 
and ultimately a firm, puckered mass is left, inclosing a 
chalky pulp. 

4. Accumulation of Gallstones. — Gallstones are otten pres- 
ent in the gall-bladder, without affording any evidence of 
their existence. In some instances, however, especially when 
they are very numerous and large, they cause local uneasy 
or painful sensations, increased after food or after exertion 
or jolting ; as well as reflex disturbance of the stomach and 
other parts, and with constitutional discomfort and depres- 
sion. Occasionally they give temporary severe symptoms 
by attempting to enter the cystic duct, then falling back 
into the gall-bladder. They may excite inflammation or 
ulceration of the mucous surface, the latter ending in perfo- 
ration or pyaemia. In rare instances such a number of 
calculi collect as to form a tumor of considerable size, having 
the general Characters of enlargement of the gall-bladder 
with the differences : 1. It feels hard and sometimes nodu- 
lated. 2. On palpation a peculiar sensation is experienced, 
of rubbing together of the calculi, compared to that of 
grasping nuts or pebbles. 3. Ajsimilar sound may be heard 
on auscultation, and occasionally loud rattling is perceptible 
on shaking or moving the patient. Occasionally local 
peritonitis is excited by this enlargement, becomes adherent. 
When such a tumor exists there are sensations of weight 
and uneasiness on moving from side to side. The course of 
these cases is very slow. 

5. Cancer. — The signs of this rare disease are : 1. Lanci- 
nating pains with tenderness in the region of the gall-bladder. 



282 



2. A tumor 7 having the characters of enlarged gall-bladder, 
feeling firm, resistant, irregular, and nodulated, without pe- 
culiar sensation of gallstones ; adherent and fixed ; growing 
rapidly. There are evidences of cancer in other parts, with 
marked cancerous cachexia. A fistulous communication with 
the intestines is often formed. Gallstones are present. Jaun- 
dice and vomiting are common. 

Gallstones — Biliary Calculi — Cholelithiasis. 

Etiology and Pathology. — There is uncertainty as to 
the mode of origin of gallstones. The chief views may be 
stated : 1. They are the result of inspissation and concentra- 
tion of bile. 2. They depend upon certain biliary ingredients 
being in excess, as cholesterin and coloring matters. 3. The 
bile has some abnormal composition, either when first formed, 
or as the result of subsequent chemical changes, which pre- 
vents it from holding certain elements in solution, and hence 
the deposit. Calculi has been attributed to deficiency of soda, 
with excessive acidity ; excess of lime, causing a separation of 
pigment ; decomposition of the salts of soda with biliary acids, 
or decomposition of the latter, with precipitation of choles- 
terin and pigment. 4. They originate in plugs of mucus, 
epithelium, or foreign bodies (worms, fruit-stones, &c), upon 
which the ingredients of the bile are afterwards deposited. It 
is probable that each of these views is correct in different 
cases, and when once the formation of a gallstone has com- 
menced, its increase may be due to some other cause than that 
which originated it. A catarrhal state of the gall-bladder and 
ducts favors the production of calculi, either by inducing stag- 
nation, or by the mucus then formed favoring decomposition 
of bile, or adding carbonate of lime to it. This decomposition 
has been attributed to the absorption of ferment from the 
intestines. 

Predisposing causes of gallstones are: advanced age; the 
female sex; sedentary habits; habitual constipation; over- 
indulgence in animal food and stimulants; organic diseases of 



283 



the liver, gall-bladder, or ducts, interfering with the escape of 
bile; drinking water containing excess of lime. 

Anatomical Characters.—- The most frequent original 
seat of biliary calculi is the gall-bladder; they may be found 
in any portion of the ducts or in the liver. The number 
varies from one to hundreds or thousands; usually several are 
found. There is a wide range in size, in an inverse ratio to 
the number; several may be cemented together, forming a 
large concretion. Originally most of the calculi are round or 
oval, but when numerous, by rubbing together they become 
worn and angular, presenting flat or concave facets, occasion- 
ally actual articulations. In the ducts they exhibit curious 
shapes, branched, coral-like, &c. They present an endless 
variety of tints, from white to black, blue, green, red, &c, 
according to their composition; may be translucent. They 
have a greasy or saponaceous feel, with a waxy, brittle consist- 
ence, being readily cut or crushed; sometimes very firm. 
Most lie in water when recent; some float, and most will after 
having been dried. The structure is rarely homogeneous and 
uniform. After a calculus has existed some time, a section 
shows three parts, named from within out, — the nucleus, of 
which there may be more than one ; the body, which is often 
in concentric layers, or presents a radiated appearance; and 
the crust, this being usually smooth externally, but occasion- 
ally wrinkled, rough, or tuberculated and warty. The layers 
become lighter in color from the centre towards the circum- 
ference; not always. The chemical composition is very variable, 
but the most common ingredients are cholesterin and bile-pig- 
ments, with a little lime or magnesia. To these may be 
added biliary and fatty acids, generally combined with lime; 
modified bile-pigments; phosphates, carbonates, salts of soda 
or potash in small proportions, and metals, (iron, copper, and 
manganese). The nucleus is often made up of mucus and 
epithelium, and the former may unite the different parts. 

The morbid conditions produced by gallstones are : 1. 
Irritation, inflammation, suppuration, ulceration, pyaemia or 



284 GALLSTONES, ETC. 

perforation, of the gall-bladder or ducts, the last in different 
directions, into the stomach, duodenum, peritoneum, or 
externally through the abdominal wall, rarely into the colon, 
portal vein, pleura, pelvis of the right kidney, or vagina. 
Fistulas may be left. 2. Inflammation and abscesses in the 
liver, if lodged there ; or formation of a cyst around the 
calculi. 3. Obstruction of some of the ducts in the liver, or 
of the hepatic, cystic, or common duct. 4. Obstruction of 
the intestines by a large calculus, this having entered through 
a fistulous communication of the gall-bladder. 5. Inflamma- 
tion, ulceration, or gangrene of the bowel, with perforation. 

Symptoms. — The passage of a gallstone along the duct to 
the intestine — biliary or hepatic, colic — usually severe; not 
always. A sudden, intense pain in the right hypochondrium, 
often coming on just after a meal or after effort ; constricting, 
griping, tearing, burning, boring, etc.; it shoots over the abdo- 
men, round the side, to the back, or toward the right shoulder. 
The patient doubles up, rolls about, as in ordinary colic, 
groaning and pressing upon the abdomen, which gives some 
relief, there being generally no tenderness at first. The pain 
may subside, leaving a dull aching ; urgent paroxysms return 
at intervals. The attacks occasion exhaustion, signs of col- 
lapse, an anxious countenance, faintness which may end in 
syncope, and cramps of the abdominal muscles, but no fever. 
Sympathetic vomiting is frequent; sometimes hiccough. 
Occasional symptoms are spasmodic tremors or convulsions, 
and rigors. In a day or two, if the gallstone reach the com- 
mon duct, there are the usual signs of obstructive jaundice. 
When the calculus reaches the duodenum the suffering sub- 
sides with relief, and the jaundice disappears. In the majority 
of cases calculi pass by the bowels and are discharged, some- 
times in great numbers, without any further mischief. They 
may be detected by washing the stools through a sieve. 
Rarely they pass into the stomach and are vomited. 

The intensity of the pain is not in proportion to the size of 



DIAGNOSIS OF CHRONIC LIVER DISEASES. 285 

the concretion reaches the common duct ; this is larger than 
the cystic duct ; it increases again as the orifice is approached. 
Jaundice may be slight, when the calculus is angular it leaves 
room for the bile to flow, or its passage is sometimes too rapid 
for the appearance of jaundice ; this may be permanent and 
extreme, owing to the impaction of a stone. It is important 
to look for the calculi in the stools, by their shape, number, 
&c, an opinion can be formed whether any remain, and 
their characters. When one large gallstone has escaped other 
smaller ones often follow without causing any particular dis- 
turbance. Sometimes the pain subsides, but no calculus is 
passed, because it returns to the gall-bladder. Sometimes 
pain and soreness remain after the escape of a concretion into 
the duodenum, owing to nervous irritability or to local 
irritation of the nerves; inflammation may be excited indi- 
cated by pain and tenderness with fever. The symptoms of 
hepatic colic are due to the passage of grit or inspissated bile. 
An attack may end fatally, from its intensity and collapse, 
irrespective of the serious morbid changes a gallstone is liable 
to set up, any one of which may cause death. 

General Diagnosis of Chronic Liver Diseases. 

The main elements in the diagnosis of chronic hepatic 
diseases, from other affections and from each other, are : 1. 
The general history of the patient may show some known cause 
of certain liver complaints, especially abuse of alcohol; over- 
eating, deficient exercise, and luxurious habits; residence in 
tropical climates or malarial districts; the previous occurrence 
of dysentery or ague; or syphilitic infection. Family history 
may aid in diagnosis, if indicating a cancerous taint ; the age 
and sex deserve consideration. 2. The constitutional condition 
is important. Some state in which lardaceous or fatty liver is 
likely; signs of the cancerous cachexia, syphilis, or cirrhosis. 
The absence of constitutional disturbance is sometimes service- 
able in diagnosis. 3. The presence or absence of symptoms 
referable to the liver, their nature, intensity, and the history of 



286 DIAGNOSIS OF CHEONIC LIVEE DISEASES. 

their progress, deserve careful attention, as pain and tender- 
ness ; jaundice ; ascites and other evidences of portal obstruc- 
tion. 4. Physical examination is valuable. 5. The state of 
other organs may afford aid, by revealing local manifestation 
of some constitutional disease, as cancer in the stomach, waxy 
kidney ; or some condition with which hepatic derangement is 
associated, any ulceration in the alimentary canal, gastro- 
enteric catarrh, or a state of the heart which obstructs the 
circulation. 6. The rapidity of the progress of a case to the 
time seen, its subsequent course, and the results of treatment, 
are important in difficult cases. 

Physical examination requires special attention in detecting 
the characters of enlargements or contractions of the liver and 
enlargements of the gall-bladder. 1. Enlargements. The ex- 
tent, direction, and rapidity of growth. 2. Whether the liver 
is normal shape and outline, or presents outgrowths or irregu- 
larities. 3. The condition of the surface and margins as to 
smoothness, nodulations, &c. 4. The consistence and other 
sensations generally, any special prominences, including 
fluctuation, hydatid fremitus, &c. 5. Whether there is any 
evidence of local peritonitis as friction-fremitus sound, or 
adhesions to the abdominal Avail. 6. Occasionally it is 
requisite to use the exploratory trocar. The gall-bladder 
should be noticed whether it is altered alone, or with the liver, 
and vice versa. 

The Causes of enlarged liver are: 1. Congestion, especially 
mechanical. 2. Accumulation of bile from obstruction in the 
ducts. 3. Albuminoid disease. 4. Fatty infiltration. 5. 
Hydatid cysts. 6. Cancerous and other growths. 7. Hepa- 
titis, when ending in suppuration. 8. Cirrhosis in its early 
stage, and exceptional instances, when advanced. As rare 
causes may be mentioned. 9. Simple hypertrophy. 10. 
Syphilitic gummous hepatitis. 11. Tubercle. 12. Lym- 
phatic growths. 13. A peculiar enlargement with vitiligoidea. 

The chief practical difficulties in diagnosis are : 1. Hepatic 
enlargement, sometimes changes in shape and other characters, 



DIAGNOSIS OF CHRONIC LIVER DISEASES 287 

I 

may be simulated by the normally large size of the organ in 
children ; congenital malformation ; pressure by a rickety or 
otherwise deformed thorax ; the result of tight-lacing ; depres- 
sion by various morbid conditions in the chest, pleuritic 
effusion and tumors ; elevation towards the chest by abnormal 
conditions in the abdomen. Distension of the colon w T ith gas 
may give signs simulating atrophy. 2. Morbid states of other 
structures often give signs of hepatic derangement; or they 
may put these in the background. Enlargement may be 
simulated by a contracted state of the right rectus muscle; 
inflammation and suppuration in the abdominal walls ; 
accumulation of fseces in the colon ; tumor in connection w r ith 
the right kidney, suprarenal capsule, or peritoneum. Scirrhus 
of the head of the pancreas interferes with the escape of bile 
from the liver, and causes its enlargement, with jaundice. 
The coexistence of ascites, chronic peritonitis with effusion, 
renders physical examination unsatisfactory. The use of the 
trocar is then most serviceable, to remove the fluid. Liver 
disease is obscured by symptoms referable to a morbid state of 
some other organ, as cancer of the stomach, etc. Sometimes 
the liver becomes so enormous in hydatid disease as to fill 
the abdomen, and it becomes impossible to tell exactly where 
the enlargement commenced. The history as to where it 
started, and its greater prominence about the hepatic region 
may clear up the difficulty. 4. In instances the liver is 
affected with two or more morbid conditions, as cirrhosis with 
fatty or albuminoid disease. Hydatid tumor may be con- 
founded with distended gall-bladder; soft cancer; right pleu- 
ritic effusion; abscess which has become chronic; aneurism; 
cystic disease of the kidney; or hydatids outside the liver. 
Cancer may be simulated by syphilitic disease ; waxy liver, if 
combined with cirrhosis, or if some parts of the liver are more 
affected than others, causing local projections; other forms of 
cirrhosis with enlargement ; multilocular hydatid disease. 

Pain referred to the hepatic organs may be simulated b\ 
painful affections of the superficial structures, either muscular 



288 GENERAL PROGNOSIS. 

or neuralgic ; gastric and duodenal disorders, either functional 
or organic; intestinal colic; accumulation of faeces in the 
colon ; aneurisinal, pancreatic, and other tumors pressing on 
the nerves ;' passage of a renal calculus ; pleurisy ; the pain in 
hypochondriasis; local peritonitis. The passage of a gall- 
stone is indicated by the individual in whom it occurs, the 
past history, and the symptoms present, by jaundice and the 
escape of calculi in the stools. Gallstones are commonly 
formed in organic disease of the liver or gall-bladder. Simple 
hepatalgia is difficult to make out. 

General Prognosis. 

The prognosis of a chronic hepatic disease depends upon its 
nature ; the degree; the escape of its secretion prevented, and 
its circulation impeded; the constitutional condition; the 
state of other organs ; and the possibility of removing any 
causes of the disease ; the results of treatment. Fatty and 
lardaceous disease are very slow in their progress; do not seem 
to hasten a fatal issue, though they are little amenable to treat- 
ment. Cancer is fatal and rapid in its course, if of the softer 
kind. Hydatid disease is chronic and unattended with dan- 
ger ; it may be cured in many cases by appropriate treatment. 
It may prove dangerous by rupturing, becoming inflamed 
and suppurating, or some of its contents being discharged into 
the bile-ducts, blocking them up. Syphilitic liver can be 
much improved by early and proper treatment. The different 
forms of atrophy are serious in their prognosis, though slow in 
progress. In cases of cirrhosis, if the ascites can be got rid 
of, a result which may be attained, the patient may be restored 
to comparatively good health and live many years. Serious 
hemorrhage from the alimentary canal is liable to occur in 
cirrhosis. Gallstones have many dangers attending them. 
Examination of calculi passed, size, number, and shape, will 
aid in determining whether any remain, and whether the 
attacks of hepatic colic are likely to roccur. 



GENERAL TREATMENT. 289 

General Treatment. 

The treatment of hepatic disease should be conducted on 
simple principles. 

1. The diet needs careful supervision, adapted to the consti- 
tutional condition, nutritious, containing abundant protein 
elements; simple and easily digestible, caution in the use of 
alcohol, hot condiments, fatty, amylaceous, saccharine sub- 
stances, and rich articles of diet generally. In many cases it 
is important to forbid stimulants, or allow light wines; if 
spirits are needed, they should be given much diluted and in 
restricted quantities. The patient may take much salt with 
food. 

2. Hygienic management is in some cases important. The 
ordinary measures for improving the general health; remove 
from a tropical climate or malarial district; cessation of seden- 
tary and luxurious habits generally, a sufficient amount of 
exercise in the open air taken daily ; and maintain free excre- 
tion of the skin by the aid of baths. 

3. Treatment against some constitutional morbid condition 
proves serviceable, and may have a direct influence on the 
liver, which applies particularly to fatty, lardaceous, and syph- 
ilitic disease. General tonic treatment and remedies for 
improving the blood are beneficial, as the various preparations 
of iron, strychnine or nux vomica, iodide of potassium or 
iron, muriate or corbonate of ammonia, have been- found to 
influence the size of lardaceous liver. Iodide of potassium 
is the remedy for syphilitic disease. 

4. The medicines which are believed to act immediately on 
the liver, influencing its secretory functions, named cholagogues, 
are podophyllin; leptandrine; nitric and muriatic acids, either 
externally or in the form of bath ; taraxacum and caseara 
sagrado. Clinical observation affords evidence that in certain 
morbid conditions, when the bile is deficient, these remedies 
decidedly increase it. This is due to their aiding in removing 

22* 



290 GENERAL TREATMENT. 

some state which impedes the formation of bile, or in promot- 
ing its discharge. It is certainly injurious to get into the 
habit of constantly taking podophyllin, etc. A dose of podo- 
phyllin now and then is serviceable. A mixture containing 
nitro -muriatic acid with extract of taraxacum enjoys consider- 
able repute, in congestion of the liver and the earlier stages of 
cirrhosis ; probably these medicines act mainly through their 
direct action upon the alimentary mucous membrane. Nitro- 
muriatic acid bath (Si of nitric and 5ij of hydrochloric to a 
gallon of water at 90° to 98° F.), in which the feet are placed, 
and then the inside of the upper and lower extremities and 
the abdomen are sponged over freely. This bath benefits 
those suffering from disordered liver. 

5. Symptoms referable to the ailmentary canal call for 
treatment in liver diseases, as gastric or enteric catarrh, con- 
stipation, flatulence, hemorrhage, &c; or there may be organic 
disease in the stomach or intestines. These conditions must 
be treated by alkalies and their carbonates, citrates, tartrates, 
and other vegetable salts; different bitter infusions or tinc- 
tures ; saline aperients and mineral waters. Keep the bowels 
regular without strong purgatives. 

6. Jaundice and ascites have been considered. Early and 
repeated, removal of fluid by paracentesis in ascites from cirrhosis 
as a means of cure, a treatment which has of late received 
support from our best authors, and from communications in 
the medical periodicals. 

7. Local applications aid to relieve pain and congestion, 
such as dry heat, poultices and fomentations, to which ano- 
dynes may be added, sinapisms, anodyne plasters, dry cupping, 
etc. 

8. Look to other organs, and treat them, if required, par- 
ticularly the heart, a diseased condition of which may be the 
immediate cause of hepatic symptoms. The kidneys must also 
receive careful attention. 

A hydatid tumor requires operative interference. No known 
drug has any influeuce upon the parasite, a spontaneous cure 



GENERAL TREATMENT. 291 

being rare. When the growth attains some size and becomes 
a source of trouble, this course of treatment should be adopted, 
it should not be delayed too long. There is much difference 
of opinion as to the best plan of operation. The principal 
methods are : 1. Puncture with a trocar and canula, and 
evacuation of the fluid through the latter. 2. Puncture and 
subsequent injection of the cyst with some irritating liquid, to 
excite inflammation, such as bile or tincture of iodine. 3. Re- 
moval of the contents through a large incision. 4. Gradual 
opening of the cyst by the repeated application of caustic 
potash to the abdomen over the most prominent part of the 
tumor. 5. Puncture of the tumor with needles and transmis- 
sion of electric shocks through it. Some assert that all that is 
necessary is to evacuate the fluid, and that then the parasite 
will die. Others, that it is necessary to excite inflammation. 
The evidence is in favor of the simple use of the trocar. Some 
recommend a very small one, others a very large one; 
there is a difference of opinion as to whether it is requisite to 
remove the whole of the fluid, some using an exhausting 
syringe to draw it off. Dr. Murchison advocates the use of 
a fine trocar. The canula should be removed before the whole 
fluid has been drawn, as it ceases to flow in a full stream ; pass 
a wire through the tube to see that it is not stopped up by a 
hydatid vesicle. The object is to prevent the entrance of 
air, one of the main dangers; it tends to supperation. Another 
danger is the escape of fluid into the peritoneum ; to prevent 
this pressure should be made over the punctured portion of the 
abdomen during the removal of the canula. The opening 
should be made over the most prominent part of the tumor. 
Local ansethesia may be induced. After the operation close 
the opening with lint steeped in collodion; apply a compress 
and bandage to it. Absolute rest three days, an opiate given 
at once and repeated if necessary. If the fluid collects again, 
repeat the operation, not too soon, as the enlargement may be 
due to inflammatory effusion. In cases which are successful 
considerable fullness may remain some months. Should the 



292 DISEASES OF THE SPLEEN. 

tumor be large its walls are thicker and less elastic, use a large 
trocar. A free incision is admissible when suppuration has 
occurred, or a large trocar may be used and an elastic tube 
left in, the cyst washed out with carbolic acid solution. The 
events which may occur with hydatid tumor must be treated 
on ordinary principles. 

During the passage of a gallstone the measures are : 1. 
Anodynes; opium or morphia in full dose, subcutaneous in- 
jection of the latter; belladonna, hyoscyarnus, chloroform 
and ether, by inhalation. 2. To treat certain symptoms, 
especially vomiting and collapse. Apply fomentations, poul- 
tices, or anodyne applications constantly over the hepatic 
region, or put the patient in a warm bath. Drink a warm 
solution of bicarbonate of soda (5i or Sii to Oj). Large 
warm enemata may be beneficial. For the prevention of 
gallstones attention to diet and hygiene is essential, and 
the use of remedies which improve the state of the alimen- 
tary canal, or those which act on the liver. It has been 
supposed that they can be dissolved after their formation, 
by means of a mixture of turpentine and ether, chloroform, 
alkalies, Or [alkaline mineral waters.' It is very doubtful 
whether either of these has any such effect, but alkalies 
and mineral waters often do a great deal of good in these 
cases. The results from gallstones must be treated as they 
occur. Inflammation about the gall-bladder requires poultices 
and fomentations. . If pus forms, or if much fluid collects, 
it is sometimes requisite to puncture the cyst and let it 
out, leavinga fistula. 



CHAPTEK VI. 
DISEASES OF THE SPLEEN. 

Clinical Characters. — 1. The spleen may be diseased 
without local morbid sensations. When enlarged, it causes 



DISEASES OF THE SPLEEN. 293 

a sense of fullness and tension about the left hypochon- 
drium, with pain and tenderness. 2. The constitutional 
condition. In prolonged cases a state known as " splenic 
cachexia" is induced, characterized by extreme anaemia, 
the mucous membranes being pale and bloodless, and the 
face presenting a waxy, or sometimes an earthy, sallow 
appearance ; great debility ; wasting, not usually rapid ; 
sense of prostration aDd dullness ; shortness of breath on 
any exertion, with hurried breathing, chiefly due to the 
anaemia; tendency to hemorrhages, in the form of epistaxis, 
bleeding from the gums, and petechia? under the skin; 
oedema of the legs and eyelids, or general dropsy. 3. 
Symptoms from pressure of an enlarged spleen on sur- 
rounding parts, the diaphragm, the dyspnoea thus increased, 
bronchial catarrh, vomiting, excited by pressure on the 
stomach. 

Physical examination of a splenic tumor shows : 1. It- is 
extra-pelvic, occupies mainly the left hypochondrium, being 
felt to come from beneath the margin of the thorax. In 
its growth it tends toward the front of the abdomen, down- 
wards and to the right; ultimately it extends to other 
regions, and appears superficial, can be separated posteriorly 
from the mass of the dorsal muscles. Percussion shows increase 
in area of splenic dullness, upwards or backwards; it 
rarely reaches above the fifth rib, and does not extend to the 
spine. There is a sense of resistance, deficient elasticity of 
the ribs. 2. The form is that of the spleen exaggerated. 
The anterior border can be felt obliquely down and to the 
right, sharp and thin, presenting notches or shallow exca- 
vations. The lower end is rounded. The outline of the 
spleen may be visible. 3. The tumor feels firm and solid ; 
may give a sensation of elasticity; fluctuation extremely 
rare. The surface smooth, may be irregular. 4. An im- 
portant character of splenic tumor is a great mobility. 
Generally more readily moved in all directions by manipu- 
lation and respiration than any other tumor; often felt below 



294 CONGESTION OR HYPEREMIA OF THE SPLEEN. 

the ribs after a deep inspiration, when otherwise imper- 
ceptible. Posture also affects it markedly. 5. A splenic 
murmur may be heard. 

Difficulties in recognizing enlargement of the spleen are: 1. 
Not sufficiently large to come below the margin of the thorax; 
then can only be made out by percussion. 2. When large, it 
may be kept up by the costo-colic fold of peritoneum, or adhe- 
sions at its upper end. 3. Adhesions may prevent any mobility 
and the tumor become fixed. 4. The enlargement may be so 
great as to obscure the outline of the spleen, the latter assum- 
ing a vertical direction. 5. Enlargement of other organs may 
conceal splenic tumors. 6. Accumulation of flatus in the 
colon may obscure its detection. The morbid conditions for 
which enlarged spleen is liable to be mistaken, or vice versa r 
are cancer about the cardiac end of the stomach; enlarged left 
lobe of the liver ; tumor of the omentum ; and tumor in con- 
nection with the left kidney or suprarenal capsule. 

Congestion or Hyperemia of the Spleen. 

Etiology. — The spleen becomes congested because of its 
great vascularity and yielding nature of its capsule. After 
every meal it is in this condition. Active hyperemia is com- 
mon in acute febrile diseases, in typhoid and intermittent 
fevers, in typhus, erysipelas, pyaemia, puerperal fever, acute 
tuberculosis, in vicarious menstruation, injury and morbid 
deposits. Mechanical congestion follows obstruction to the 
portal circulation, direct or secondary, to chronic heart and 
lung-affections. 

Anatomical Characters. — The characters of a recently 
congested spleen are enlargement, the capsule stretched and 
smooth ; increase in weight ; redness of a dark hue ; and 
diminution in consistence, the substance of the organ some- 
times quite pulpy or almost liquid. The blood is much 
increased, red blood-cells are abundant, and the splenic tissue 
increased. After long-continued or repeated hypersemia, it 



HEMOEEHAGIC INFAECTION — SPLENITIS. 295 

becomes permanently enlarged, hardened and hypertrophied. 

Symptoms. — The clinical sign of congested spleen is, the 
organ is enlarged to a great degree, and liable to vary con- 
siderably. Occasionally soft, but generally firm. Tenderness 
is common, and may be marked in acute congestion. 

Hemoeehagic Infaection — Splenitis. 

Etiology and Pathology. — The spleen is one organ in 
which emboli frequently lodge, causing hemorrhagic infarc- 
tions. May also arise from the formation of local thrombi in 
the organ. Inflammatory action is excited, when the emboli 
have septic properties, as in typhus or pyaemia, and this is 
frequent cause of splenitis. Inflammation results from injury; 
and it may occur in malarial districts, in tropical climates, or 
idiopathically. 

Anatomical Chaeactees. — Infarctions in the spleen are 
seen on a section in wedge-shaped masses, base towards the 
surface, projecting somewhat ; when deeper they are rounded. 
They vary in number and size. Originally each infarction is 
dark and firm, and surrounded by congestion ; in time changes 
take place, the coloring matter is absorbed; the mass is yellow- 
ish-white. Caseous degeneration with ultimate absorption may 
occur, a depressed cicatrix remaining ; or it may end in cal- 
cification. In pyaemia and similar affections, the infarctions 
rapidly break down, form a purulent fluid, and the spleen is in- 
flamed and congested. One or more abscesses form, sometimes 
finally involving the entire organ, being converted into a 
mere bag of pus. An abscess occasionally bursts externally 
or into the peritoneum, stomach, thorax, etc. Rarely it be- 
comes encapsuled, and undergoes curative changes, its fluid 
portion being absorbed, so that finally only a caseous mass 
remains, which may calcify. The peritoneum is often inflamed 
over the affected part. 

Symptoms. — Very rarely can embolism in the spleen and 
its results be recognized during life, but it may be suspected 
if, with some source of embolism, there should be rigors and 



296 HYPEETEOPHY LEUCOCYTH^MIA. 

fever, with local signs indicating inflammation of the spleen, 
as pain and tenderness in the left hypochondrinm ; enlarge- 
ment and vomiting. An abscess is scarcely ever diagnosed ; 
it may cause a fluctuating enlargement, or burst externally.' It 
is attended with hectic fever and rapid wasting. Should it 
rupture internally, there are the usual signs of perforation. 

Hypeeteophy. — Leucocythjemia. 

Etiology and Patholgy. — The most important form of 
enlarged spleen is that which is hypertrophy of its tissues. It 
may follow long-continued or repeated congestion, but par- 
ticularly after ague, or after residence in malarial districts, 
and the result of portal obstruction. If this hypertrophy is 
due to interference with the escape of the cells out of the 
spleen, not to excessive formation. It is most important in 
the disease named leucocythcemia or leukcemia, characterized by 
the presence of a great excess of white corpuscles in the 
blood, an increase in the lymphatic tissues in certain organs 
and structures, in the spleen and lymphatic glands, occasion- 
ally in the liver, kidneys, lungs, heart, thyroid gland, supra- 
renal capsules, in serous and mucous membranes. Virchow 
has described two forms : in one the spleen is enlarged; this is 
sometimes more common ; in the other it and the lymphatic 
glands. The increase in white blood-cells is mainly due to 
excessive format ion in the spleen or lymphatic glands; it has 
been attributed to diminished metamorphosis of these into red 
corpuscles, to their proliferation in the blood, and a new 
formation by the walls of the vessels. 

Anatomical Chaeactees. — In hypertrophy from hyper- 
emia, the spleen is increased in size and weight, sometimes 
great, but retains its normal form ; its consistence is increased, 
a section appears pale and dry, sometimes gray, or black spots 
or patches due to pigment. The tissue is quite normal, but 
increased and condensed, the trabecule being also thickened 
and firm, appearing as white lines. When the spleen is affect- 



HYPEETEOPHY — LETJCOCYTH.EMIA. 297 

ed in leucocythseima it is first congested, the cellular elements 
increasing. Ultimately it may attain enormous dimensions. 
It is not invariably firm. The increase of tissue, particularly 
in the Malpighian corpuscles, becomes enlarged; the vessels 
increasing in number, they are seen on section firm, whitish, 
irregular, scattered nodules, the surrounding pulp atrophied as 
they extend, often much pigmented. The trabecular are 
thickened. The capsule is thickened, opaque, and adhesions 
form with neighboring structures. Hemorrhagic infarctions 
or their remains are common. 

When the lymphatic glands are affected they enlarge, in 
cases forming tumors by their aggregation. They resemble 
ordinary glands, soft, smooth, uniform surface, from which a 
turbid fluid can be expressed. The cortical portion is much 
thickened. 

In the liver, the changes associated with leucocythsemia are 
in the form of little whitish spots, consisting of a soft adenoid 
tissue, composed of small cells and nuclei. The liver may be 
occupied by considerable masses of this substance, causing its 
enlargement. The deposits are mainly derived from infiltra- 
tion by elements conveyed by the blood from the spleen and 
glands, in part due to local hyperplasia of the adenoid tissue 
normally present. 

The changes in the blood, in the splenic variety of the dis- 
ease it contains an enormous number of white corpuscles ; in 
the lymphatic variety, there are abundant small cells and free 
nuclei, like those in the glands ; and in mixed cases as the 
disease apprpaches more one type or the other, does the rela- 
tive proportion of these elements vary. Other characters of 
the blood are marked, lowering of its specific gravity ; great 
diminution of red corpuscles, and iron ; increase of water ; 
and in some instances, the presence of abnormal ingredients, 
such as are usually found in the spleen, viz. : hypoxanthin, 
lactic, formic, and acetic acids. The proportion of white cor- 
puscles differs in blood taken from different parts of the body, 
being highest in that of the splenic vein. After death soft, 



298 DISEASES OF THE SPLEEN. 

yellow clots are found in the heart and great vessels, some- 
times almost purulent. 

Symptoms. — Hypertrophy of the spleen may long exist to 
a marked degree without producing any evident disturbance. 
In some advanced cases there are signs of marked splenic 
cachexia. Physical examination usually reveals the enlarged 
spleen. 

In leucocythcemia the essential clinical phenomena are: 1. 
Splenic cachexia, often attaining a high grade. 2. The phys- 
ical signs of enlarged spleen, in some instances this organ 
"being so hypertrophied as to cause general enlargement of the 
abdomen. 3. In a few cases enlarged masses of lymphatic 
glands, either externally, internally, or both ; occasionally 
signs of enlarged liver. 4. Sometimes evidences of pressure 
by the spleen on surrounding structures, especially the dia- 
phragm. 5. Peculiar changes in the blood. Prick the finger 
so as to get a drop, and examine this microscopically, when 
the increase in white corpuscles is perceptible. Subjective 
sensations in the abdomen are a sense of weight, fullness, and 
transitory pains. There are digestive derangements, and 
vomiting and diarrhoea. The disease is very chronic ; there 
is no pyrexia in the earlier periods, may be some irregular 
febrile disturbance, towards the close the temperature is 
raised persistently. Death may take place gradually from 
asthenia and exhaustion, preceded by delirium, stupor, and 
coma; or more speedily from hemorrhage, diarrhoea, and 
other complications. 

Other Morbid Conditions of the Spleen. 

1. Labdaceous Disease. — For the etiology, morbid anat- 
omy, and constitutional symptoms of this condition, the general 
account is already given. The deposit is in some cases limit- 
ed to the Malpighian corpuscles, producing the appearance 
known as the "sago-spleen," in which translucent granules 
are observed, like boiled sago. Clinically the enlargement of 
the spleen is recognized by its very hard and dense consist- 



MORBID CONDITIONS OF THE SPLEEN. 299 

ence, and by its steady growth, finally reaching extreme 
dimensions in some cases. Other organs are involved; there 
is a constitutional condition with which albuminoid disease is 
associated. 

Diagnosis. — Physical examination is requisite to positively 
recognize diseases of the spleen. The main difficulties have 
been indicated already. Leucocythseniia requires an examin- 
ation of the blood. History of cases help, if they show ex- 
posure to malarial influences, or previous attacks of ague. If 
there is obstructed portal circulation, enlarged spleen results. 

Prognosis. — Acute diseases of the spleen are rarely dan- 
gerous; chronic ones are slow in progress, except malignant ; 
if only hypertrophy the health remains good for a long time, 
and it is next to impossible to reduce it. Leucocythsemia is in- 
curable, it lasts a variable time, an average of from 12 to 15 
months. 

Treatment. — This is indicated by the descriptions of the 
various affections already given. No remedies are known to 
have special effect in reducing enlargement of the spleen, other 
than treating it on general principles. Acute inflammation 
{splenitis), a rare disease, require similar management to that 
of acute hepatitis; an emetic, followed with catharsis, and a 
febrifuge. Fomentations over the left side, or sinapism, 
pediluvium, etc. Chronic forms require supporting measures 
throughout. An abscess, which may be enormous, may be 
evacuated in various directions, as described in hepatic abscess, 
and must be similarly treated. Its discrimination from sup- 
purations in its vicinity is very difficult. The prognosis is 
unfavorable. 

Our present knowledge does not enable us to understand 
fully the consequences of the impairment or loss of the func- 
tions of the spleen. It is well known that this organ may be 
removed from inferior animals without the destruction of life 
or serious injury to health. This fact goes to show that what- 
ever may be its functions they are adequately performed by 



300 MORBID CONDITIONS OF THE SPLEEN. 

other organs in its absence. There is reason to believe that 
this statement is applicable to man as well as to inferior 
animals. A case of much interest, as bearing on this point, is 
communicated by Dr. John L. Alston, of Texas, who, during 
the late civil war, served in the army of the rebellion. His 
account of the case is: "¥m. H. Worden, aged about 
eighteen years, in fine health, was wounded on the 8th of 
October, 1861. The ball entered the integument one inch to 
the left of the spinous process of the fourth lumbar vertebra, 
and pursued a diagonal course upward, coming but between 
the ninth and tenth ribs half-way between the sternum and 
spine. The ball must have entered the cavity of the abdomen, 
for at the orifice where it made its exit nearly the whole of the 
spleen protruded. The organ was not wounded, and it had a 
fresh and florid appearance as if it were not much strangulat- 
ed. The protruding portion measured three and a half inches 
in length and two and a half inches in width. He came under 
my observation on the third day after the wound was received. 
Surgeon Rice, of Gen. Cheatham's staff, agreed with me that 
the protruding substance was the spleen. I threw a strong 
ligature around it, and each day tightened the ligature. It 
dropped off on the fourth day. The stump which remained 
plugged up the bullet-hole. No suppuration ensued, and he 
got well without a bad symptom. On the day after the 
ligature came off he was sitting up, and was walking about in 
five or six days afterward. He said that he had lost a great 
deal of blood when he received the wound. When he left the 
hospital he was entirely well, not seeming to suffer at all from 
the loss of his spleen." 

It would be interesting to know whether the effects followed 
in this case which are sometimes observed after the removal of 
the spleen from the dog or cat, viz., a ravenous appetite and 
ferocity of disposition. 

The spleen was removed forenlargement, by Spencer Wells, 
of London. The organ weighed, after nine ounces of blood 
had drained out of it, 5 lbs. 11 ounces. The patient, a 



REMOVAL OF OF THE SPLEEN. 301 

married woman, aged 34 years, survived the operation a little 
over six days. The annals of medical literature contain 
additional cases in which this organ has been removed for 
enlargement. The first case was in Naples, in 1549; the 
operation was performed by a surgeon named Zaccarelli. The 
patient recovered. The authenticity of this case is perhaps 
open to distrust. The second case was in Germany, in 1826. 
The name of 'the operator was Quittenbaum. The organ 
weighed nine pounds. Death followed in six hours. The 
third case was also in Germany, in 1855; the name of the 
operator, Kuckler ; the weight of the organ was three pounds, 
and death followed in two hours. 

Four additional cases of spleenotomy have been reported. 
In one of these cases the operation was entered upon with the 
expectation of finding an ovarian tumor. A large cyst was 
attached to the organ. A speedy recovery followed. The 
operator was M. Pean, and the case was reported for V Union 
Medicale, Nov. 1867. The operation in the second case was 
performed by M. E. Kceberle, and is reported in the Gazette 
Hebdomadaire, October and November, 1867. The patient 
was a woman aged 42. The patient did not recover conscious- 
ness after the operation, and died evidently from hemorrhage. 
In the third case, the patient was a groom, aged 20. The 
operation was performed by Thomas Bryant, and the case is 
reported in Guy's Hospital Reports, vol. xii, third series. The 
operation was begun at 2.30 p. m., and at 4.50 p. m. the 
patient died. The operation in the fourth case was performed 
by Thomas Bryant — patient a female aged 40. Death took 
place from hemorrhage, within a few minutes after the com- 
pletion of the operation. M. Kceberle, in the report of this 
case, cites three cases in addition to those which have been 
referred to, the operation being successful in each of the cases. 
One of these cases was in 1549. The patient recovered in 24 
days. In another the spleen escaped through a wound from a 
sword. The patient six years afterward was in perfect health. 
This was in 1678. In the remaining case the spleen made a 



302 DISEASES OF THE PANCREAS. 

hernia through'an opening of an abscess below the umbilicus. 
The patient lived five years after the removal. In the last 
two cases, it will be observed, there was no hypertrophy. 
These do not encourage the removal of the spleen. 

Diseases of the Pancreas. 

Owing to the infrequency, and their obscurity as regards 
diagnosis, affections of the pancreas require but a passing 
notice. This gland may be the seat of inflammation, acute or 
chronic. Of all the glandular organs — liver, ovaries, testes, 
kidneys, etc. — the pancreas is perhaps the least liable to 
become inflamed. Acute pancreatitis has been found, on ex- 
amination after death, to occur in cases of continued fever, of 
puerperal fever, of pyseniia, and apparently as a result of the 
employment of mercury. The morbid appearances denoting 
acute inflammation are engorgement, softening, enlargement, 
and suppuration. Gangrene has been observed. The symp- 
toms which have been observed are, pain referable to the 
epigastrium, vomiting, diarrhoea, chills, and more or less 
febrile movement. The data for determining the clinical 
history of the affection are insufficient. A discharge, by 
vomiting and stool, of a liquid resembling saliva, supposed to 
be the pancreatic secretion, has been thought to be a diagnos- 
tic symptom, but there is no reliable evidence of the correct- 
ness of this opinion. It remains to be ascertained whether 
the presence of fat in the stools is a diagnostic symptom. The 
diagnosis, with our present knowledge, is impracticable. 
Were it practicable to ascertain the existence of the affection 
before death, the indications for treatment would be the same 
as in other parenchymatous inflammations. An abscess of 
the pancreas has been known to open into the stomach. Chronic 
pancreatitis is, if- possible, even more obscure as to diagnosis, 
than the acute form of the disease. In a case observed by 
"Wilks, death followed extreme emaciation without any symp- 
toms pointing to the seat of the disease. From what has been 
stated with regard to the diagnosis, it follows that is impossible 



DISEASES OF THE PANCKEAS. 303 

to form ail opinion as to the proportion of cases in which, 
either acute or chronic pancreatitis ends in recovery. 

The pancreas is sometimes the seat of cancer, which is 
generally secondary to cancerous deposits in adjacent parts. 
In certain cases regarded as cases of scirrhus, the affection is 
chronic inflammation of the areolar tissue which enters into 
the composition of this organ, constituting an affection analo- 
gous to cirrhosis of the liver, and the two affections are apt to 
be associated. Enlargement of the head of the pancreas from 
chronic inflammation, cancerous disease, or the formation of 
cysts, may constitute a tumor discoverable by manual explor- 
ation. The diagnosis involves its discrimination from other 
tumors in the same situation. It is most likely to be con- 
founded with aneurism of the aorta and cancer of the pylorus. 
A pulsation may be communicated to the tumor from the 
aorta, and this will suggest the idea of aneurism. The diag- 
nostic symptoms and signs of aneurism of the abdominal aorta 
are to be sought for, and this affection excluded by their 
absence. Cancer of the pylorus is to be excluded by the 
absence of the gastric symptoms which usually accompany this 
affection. The connection of structural disease of the pancreas 
and fatty diarrhoea has been considered in treating of the 
latter. The presence of free fat in the alvine dejections, taken 
in connection with a tumor supposed to be an enlarged pan- 
creas, is a point of weight in the diagnosis. The absence of fatty 
dejections is not proof against, but their existence is strong 
evidence for, the supposition that the tumor is pancreatic. 

Enlargement of the head of the pancreas may give rise to 
serious results from pressure upon adjacent parts. The duct 
leading from the pancreas is sometimes compressed, and dilata- 
tion of its branches within the organ ensues. Pressure upon 
the ductus communis, involving obstruction to the flow of bile, 
is followed by the retention of this secretion, causing persis- 
tent jaundice, dilatation of the bile-ducts, and, at length, dis- 
organization of the liver. Cases of jaundice with enlargement 
of the head of the pancreas, the obstruction and retention oi 



304 DISEASE OF THE SUPRARENAL CAPSULES. 

bile have been due, not to the pressure of the pancreatic 
tumor on the common duct, but to disease of Glisson's capsule 
or cirrhosis of the liver. An enlarged pancreas may cause 
obstruction of the pylorus or duodenum, and this renders it 
difficult to differentiate the affection from cancer of the pylo- 
rus. Pressure upon the portal vein may exist to an extent to 
give rise to hydro-peritoneum. 

Calculi may form in the pancreatic ducts,, varying in size from 
that of a pea to an almond. These have been found in con- 
siderable number. In their journey along the excretory 
passage to the duodenum, they may /occasion severe pain, 
resembling that caused by biliary calculi. Paroxysms of pain 
due to the passage of pancreatic calculi, or attacks of pancre- 
atic colic, are sometimes attributed to gallstones, nor is it 
practicable, with our present knowledge, to make the differ- 
ential diagnosis. It is not very important since the indications 
for treatment are the same in either case. Clinical observa- 
tion with reference to the presence of free fat in the dejections, 
may show this symptom to be present in cases in which, with- 
out special attention, it is overlooked, and it may be found 
that this symptom is of much value in the diagnosis of affec- 
tions of the pancreas. 

DISEASE OF THE SUPRARENAL CAPSULES.— 
ADDISON'S DISEASE. 

Clinical History. — Dr. Addison first called attention to 
a series of symptoms associated with disease of the suprarenal 
bodies. One prominent phenomenon consists in a peculiar 
cachexia, which sets in gradually without obvious cause, 
characterized by increasing debility, languor, indisposition for 
bodily or mental effort, at last extreme prostration ; marked 
anaemia, the sclerotics being pearly- white; wasting, not to any 
degree, nor always observed; feebleness of the heart's action; 
the pulse very soft, weak, and compressible, and a tendency 
to faintness, sometimes prolonged attacks of syncope. Another 



DISEASES OF THE SUPRARENAL CAPSULES. 305 

feature is a discoloration of the skin, the so-called bronzed 
appearance, due to the presence of pigment-granules in the 
rete mucosum; occasionally pigment-cells. The hue varies, 
and becomes darker by degrees; may resemble a mulatto, 
or simple dingy or smoky, or brown, yellowish, grayish- 
black, etc., all over the body, usually commences over ex- 
posed parts, as the face and neck, also on the upper extrem- 
ities, in the axillae, and about the penis, scrotum, and navel. 
The palms and soles sometimes present spots of pigment. 
The mucous membranes are discolored, the lips assuming a 
mulberry hue, or spots of pigment being observed on them 
and on the inside of the cheeks, with dark streaks opposite the 
angles of the mouth. In addition there is pain in the epi- 
gastrium, sometimes severe, with vomiting, may be urgent. 
Other digestive disorders are common, and obstinate diar- 
rhoea. The course of the disease is slow, chronic ; death 
takes place by a gradual asthenia, occasionally preceded by 
nervous disturbances. Exceptionally the progress is acute 

and rapid. 

Pathology.— There are several points in the symptoms 

about which there is difference of opinion. The bronzing of the 
skin is a question what relation it bears to suprarenal disease. 
A complete destruction of these bodies may occur without 
such discoloration ; this has been observed where there was 
no suprarenal mischief. Hence, some pathologists refuse to 
acknowledge any relationship between the two. Again, a 
difference of opinion as to whether the bronzing is associ- 
ated with all forms of suprarenel disease, or one special 
variety. The morbid changes are : 1. Acute inflammation 
ending in suppuration. 2. Tubercle. 3. Cancer, always 
secondary, and of the encephaloid variety. 4. Amyloid 
disease. 5. Fibroid degeneration with hardening. 6. Fatty 
degeneration. 7. Atrophy. 8. Hemorrhage. 9. Peculiar 
alterations associated with bronzed skin. 

Besides the changes, alterations in the solar plexus and 
semilunar ganglia, atrophy of the mucous coat of the ali- 



306 ABDOMINAL, ANEURISM. 

nientary canal, with degeneration of the glands. These 
have an important influence in the pathology, the changes 
in the sympathetic nerve, branches of which are very 
abundant in the suprarenal bodies. The blood contains an 
excess of white corpuscles. 

Diagnosis.— If symptoms of failing health and cachexia 
appear, without any evident organic mischief, Addison's 
disease may be suspected. When the bronzing appears, 
there is no doubt about the nature of the case. 

Prognosis is very grave, the disease always ends fatally; a 
case may go on for a long time. 

Treatment. — All that can be done is to promote health 
and strength by a highly nutritious diet ; tonics, quinine. 

Abdominal Aneurism. 

The most important form of abdominal aneurism is that of 
the aorta. One may be found on the cseliac axis or its 
branches, the hepatic, on the mesenteric, or renal arteries, or 
iliac arteries. 

Symptoms. — The detection of a tumor, having the usual 
characters of an aneurism. Often there are signs of pressure 
on surrounding structures, and evidences of constitutional 
disturbance. The 'physical characters of an aneurismal tumor 
are: 1. It is usually seated in some part of the course of the 
aorta, but projects more to one side than the other, especially 
towards the left. It may be in other parts. 2. The shape is 
rounded, surface smooth, tumor yields on being compressed. 
3. It is quite immovable, unaffected by respiratory movements; 
if very large it may interfere with these movements. 4. A 
variable degree of pulsation, synchronous with the cardiac 
systole usually, but sometimes also diastolic, distinctly expan- 
sile, tending laterally and forwards, commonly more to one side, 
occasionally attended with a thrill. 5. Percussion reveals 
dullness, with a sense of much resistance. 6. Often a systolic 
murmur, sometimes very loud and harsh, but not always 



ABDOMINAL ANUERISM. 307 

heard, or slight, may be seated beyond the aneurism. ~No 
diastolic murmur. The murmur is influenced by posture and 
pressure. 

The points of practical importance are : 1. The signs may 
be in the back; it is essential to make examination here. 
Sometimes no sign except a murmur in this region. 2. There 
is no relation between the size of an aneurism and the pulsa- 
tion or murmur. 3. Occasionally the tumor is movable, and 
not uncommonly both pulsation and murmur are considerably 
influenced by posture, hence examine in different positions. 
Observe that the impulse does not disappear when the patient 
is in a kneeling attitude supported on the hands. 4. The 
signs may change in the progress of the case. 

The pressure-symptoms will vary with the situation of the 
tumor. The most couimon are neuralgic pains, sometimes 
severe, shooting in different directions, from pressure on 
nerves, causing permanent contraction of the flexors of the 
hip-joint ; deep gnawing pain, from erosion of the vertebrae ; 
anasarca of one or both legs, with distention of the superficial 
veins, due to pressure on the vena cava, or one of the iliacs. 
Micturition is affected at times, and albuminuria may occur 
from pressure on the renal veins. Wasting of the testis from 
obliteration of the spermatic artery. Aneurism of the hepatic 
artery is a possible cause of jaundice and ascites, by pressing 
on the neighboring duct and portal vein. 

Patients have a feeling of pulsation. The alimentary canal 
is out of order, may be obstinate constipation. Patients fre- 
quently look well, but may present a very peculiar aspect 
indicating profound illness, with anaemia, without physical 
signs of aneurism. 

Diagnosis. — The chief conditions which may simulate 
aneurism are: 1. Simple aortic pulsation. 2. The pancreas 
or a solid tumor transmitting an impulse from the aorta, or 
giving rise to a murmur by pressure. 3. A fluid accumula- 
tion, such as hepatic abscess or hydatid tumor, receiving an 
impulse from the aorta. The diagnosis from mere aortic 



308 ABDOMINL AANETJRISM. 

pulsation requires special comment. The chief facts in favor 
of this condition are: 1. It is genarally seated in the epigas- 
trium. 2. It is observed in highly . nervous and anaemic 
persons, in women, in very thin individuals, or dyspeptics. 

3. There are no signs of pressure, nor any pain or tenderness. 

4. The impulse is scarcely ever expansile and lateral, tends in 
a forward direction, is never attended with a thrill; no in- 
crease in dullness, or evident tumor, if a murmur is present, it 
is soft and blowing or whiffing, never harsh or loud. Some 
cases are difficult to diagnose, the progress must be watched, 
and the effects of treatment observed. 

An aneurism may exist without physical signs. Occasion- 
ally it presents the characters of a solid tumor without any 
pulsation or bruit. If deep pain near the spine, and if the 
constitution shows signs of being gravely disturbed, aneurism 
should be suspected and examination made repeatedly, behind 
as well as in front. 

Treatment. — The rapid-pressure treatment, employed by 
Dr. W. Murray, of ISewcastle-on-Tyne. The plan is to keep 
the patient under chloroform, and apply a tourniquet over the 
aorta above the tumor, maintaining steady and constant pres- 
sure until all pulsation has ceased in the aneurism on remov- 
ing the tourniquet. The blood coagulates in the sac, and 
afterwards collateral circulation is set up. The results of this 
treatment are certainly such as to recommend its adoption in 
appropriate cases^ if other measures do not appear to be pro- 
ducing good effects. If the aneurism is high up, distal pres- 
sure may possibly be of service. Pain is a symptom often 
calling for interference, and is best relieved by chloral, or 
subcutaneous injection of morphia. Posture may influence it 
considerably. It is important to attend to the state of the 
digestive organs. A belladonna plaster should be worn con- 
stantly over the aneurism. 

For the pathology, etc., of this kind the reader is referred to 
aneurism of the thoracic aorta. 



DISEASES OF THE URINARY ORGANS. 309 

CHAPTER VII. 
DISEASES OF THE URINARY ORGANS. . 

Congestion. 

Etiology. — The causes are : Sudden exposure and check 
of perspiration ; overdose of cantharides, turpentine and 
other irritants; active renal congestion or disturbance in 
connection with, febrile and inflammatory diseases, etc. 
Passive congestion is incident to heart-disease, pulmonary ob- 
struction, as in emphysema or pleuritic effusion; when 
pressure impedes the circulation in the vena cava, or renal 
veins, as in abdominal tumors or pregnancy. 

Symptoms. — Pain in the lumbar region, increased on 
pressure, with tenderness ; urine scanty, highly colored, 
sometimes bloody ; may contain albumen, and give fib- 
rinous casts. Often voided with difficulty, attended with 
burning pain, etc. 

Diagnosis. — Active congestion has a known cause : be- 
gins suddenly. Passive congestion is due to some other 
organic disease, is variable, not progressive. Occasionally 
it is difficult to distinguish this from Bright's disease. This 
distinguishes them from permanent diseases of the kidneys. 

Treatment. — Active congestion requires cooling saline 
purgatives and diuretics. Fomentations over the lumbar 
region ; warm pediluvium ; hip-baths, and emollient drinks. 
These measures should be used industriously until relief is 
reached. 

URiEMIA. 

Uremia takes its name^from supposed excess of urea which 
the kidneys secret, being retained in the blood. The ques- 
tion remains unsettled, whether it is urea, or] an ammoniacal 
educt from its decomposition in the blood. Without demon- 
strating the latter, the former is considered most probable. 



310 NEPHRITIS. 

Uraemia may occur in the progress of diphtheria, scarlatina, 
etc. 

Symptoms. — Headache, often fixed behind the orbits or 
neck; pressure over the forehead or vertex; dimness of vision; 
irritability of voluntary muscles and twitching; nausea and 
vomiting; diarrhoea; epileptiform convulsions; face pale and 
pupils dilated; stupor ending in fatal coma and death. 

Treatment. — Use measures to promote the excretion of 
urine. Apply heat and moisture to the loins, or dry cupping. 
Promote action by the skin with hot air or warm vapor baths, 
and treat other symptoms as they arise. For epileptiform 
attacks, inhale ether or chloroform. Sinapisms to the back of 
the neck and limbs. Use saline cathartics; diuretics and 
diaphoretics. 

Nephritis. 

In the present state of urinary pathology, it is common to 
merge the topic of inflammation of the kidney (except suppura- 
tive pyelitis) as distinct from active renal congestion — in 
Bright's disease. If this be questionable as a matter of patho- 
logical system, it has at least practically no disadvantage ; as 
the symptoms of nephritis are included in one or other of the 
affections named; and so is its treatment. We may submit, 
therefore, to the usage of authority upon this point, without 
hesitation. The symptoms of acute pyelitis (inflammation of 
the pelvis of the kidney) are essentially those of renal conges- 
tion, intensified; with tenderness on pressure over the kidney, 
and fever, until suppuration is established ; then, purulent 
discharge for a variable time from the kidneys. Before pus 
appears, blood, in small quantity, mucus, and renal epithelial 
cells may be found in the urine. A tumor in one of the 
lumbar regions may precede for a while the escape of the pus. 
To such a state of things the term pyonephrosis is sometimes 
(though not desirably) applied. Hydronepohosis is a dropsical 
accumulation of water in the kidney. 

Treatment. — Active catharsis; diuretics; diaphoretics; 



311 



sinapisms, fomentations, and poultices over the lumbar region. 
Drink flaxseed tea with lemon-juice in it. 

Bright's Disease. 

Definition. — Albuminuria, due to structural change in 
the kidneys ; disease of the kidney, characterized by albumi- 
nuria and dropsy. 

Varieties or Stages — Authorities differ as to these. 
Bright believed there were three varieties. Dr. G. Johnson 
asserts two, the desquamative and non-desqaumative nephritis. 
Frerichs considers them to be stages of the same affection, and 
admits three stages, essentially, of hyperemia, exudation, and 
degeneration. Anatomically, we have the large, smooth, 
white kidney, the small, smooth kidney, the granular uncontract- 
ed kidney, and the granular contracted kidney. We may safely 
follow Roberts, in dividing Bright's disease, first into acute 
and chronic. The latter is then divided into, 1. Cases which 
have lapsed from the acute state (smooth, white, generally 
large kidney); 2. Cases chronic from the beginning (granular, 
red, contracted kidney); 3. Cases associated with waxy or 
amyloid degeneration of the kidneys. 

Causation. — Bright's disease is one-third more common in 
males than in females. The greater number of cases occurs 
between the ages of 45 and 65. Acute Bright's disease is 
most often produced by cold and dampness; next by scarlet 
fever, pregnancy, or violent intemperance. The acute form is 
most common in early life. 

Chronic Bright's disease is promoted by exposure to cold 
and wet; is caused by abuse of spirituous liquors, very often. 
Other predisposing causes are gout, constitutional syphilis, 
and affections of the bladder and urethra. 

Symptoms. — Acute Bright's Disease. — After exposure to 
cold, or a drnnken fit, or scarlet fever, the patient is seized 
with chilliness, headache, nausea, vomiting, paiu in the back 
and limbs, checking of perspiration, and oppression' in breath- 
ing. Fever follows; and the face, trunk and limbs become 



312 bright's disease. 

puffy with anasarca. Effusion may also occur into the pleura 
or peritoneum. 

The urine is scanty, heavy, and dark in color, from the 
presence of blood; and very albuminous. The disposition to 
void it occurs more frequently than during health. The 
deposit from it, under the microscope, shows blood-corpuscles, 
loose renal epithelium, free nuclei, tube-casts, and shapeless 
masses of fibrin and debris. 

After one, two, or three weeks, or even a longer period, the 
attack proceeds to one of three terminations : recovery, death, 
or lapse into the chronic state. Death results through 
ursemia, or from secondary pneumonia, pleurisy, peritonitis, 
pericarditis — or hydrothorax, oedema of the glitois, hydroce- 
phalus, or ascites. Probably two-thirds or more of the cases 
of acute Bright's disease recover. 

Treatment. — Cupping the loins, hot water 'or hot air or 
"blanket" bath, active purging, as with cream of tartar and 
jalap, or citrate of magnesium, and diaphoretics, as citrate of 
potassium or liquor amnion, acetat. The diet should be 
liquid and simply nutritious. Flaxseed tea with lemon juice 
in it, drank freely, is an excellent and much relished diuretic. 
Chronic Bright's disease comes on slowly, it is seldom 
detected until after the lapse of months or years. Gradual 
loss of strength, pallor or puffiness of the face, shortness of 
breath, and frequent disposition to urinate, are early signs of 
it. But they are not always present ; the denouement of the 
disease may be by a convulsion, oedema of the lungs, amauro- 
sis, or some violent local inflammation. 

Symptoms of a well-marked case (not all present in every 
instance) are : albuminous urine, deposits of tube-casts and 
renal epithelium, dryness of skin, frequent micturition, es- 
pecially at night, general dropsy, or local effusions into the 
cavities, indigestion, anaemia, uraemic effects, (headache, diz- 
ziness of sight, convulsions, coma, vomiting, diarrhoea), en- 
largement of the heart, and secondary inflammation. Bron- 
chitis is especially common. 



313 

The progress of the case is usually interrupted by ex- 
acerbations and intervals ; each fresh attack leaving the 
patient manifestly worse than before. Such attacks much 
resemble acute Bright's disease ; they are sometimes referred 
to known causes ; the intervals may last weeks, months, 
or even years. 

In prognosis, the tendency is always toward a fatal re- 
sult. About one-third die of uraemic poisoning. A con- 
siderable number die of local dropsical effusions. One-fifth 
from secondary pneumonia, pericarditis, or pleurisy. The 
rest, by exhaustion from anaemia, indigestion, and anasarca, 
or the complications of apoplexy, cirrhosis, phthisis, in- 
testnal ulcerations, etc. 

Diagnosis. — The presence of albumen in the urine, with 
dropsy, not of sudden origin or brief duration, is pathog- 
nomonic of this affection. The tests for albumen, by heat 
and nitric acid, are readily applied. The microscope will 
show also free renal epithelium and tubular casts in the 
urine ; in advanced cases, the casts are sprinkled with oil- 
dots. The solids of the urine, especially the urea, are re- 
duced below the normal amount. 

Pathology. — Degeneration of the structure of the kid- 
ney induces albuminuria, by allowing the serum of the 
blood to pass almost unchanged through the cortical sub- 
stance into the tubuli uriniferi. The deficiency of urea is 
due to the same impairment of secreting power. The con- 
sideration of the different varieties of renal degeneration 
would be too complex a subject for these pages. The 
reader is referred for it to the standard treatises on the 
subject. 

Treatment. — The indications in every case of Bright's 
disease are : 1. To hinder the progress of structural change 
in the kidney. 2. To prevent uraemia and secondary in- 
flammation. 3. To palliate concomitant symptoms or states, 
as anaemia, dropsy, dyspepsia, etc. 

Regimen or hygienic management is of the utmost im- 



314 bbight's disease. 

portance for the first of these ends. Avoidance of exposure 
to cold, wet, or great fatigue ; the reform of intemperance, 
if it has existed, or of other excesses — will be indispensable. 
Clothing should be sufficiently warm, with flannel next to 
the skin. Bathing frequently, at such temperature as is 
borne without either chill or relaxation, is to be recom- 
mended. The bowels should be kept regularly open. 
Nourishing diet, of which milk may generally be part, is 
of consequence. 

Iron will do more good than any other medicine, unless it 
be cod-liver oil in persons of strong stomach. They may be 
very well combined. The tincture of the chloride of iron is 
as good as any other chalybeate, as a general rule. With 
some, the citrate of iron in solution, or a carbonate of the 
iodide, will agree more readily. 

It is very doubtful whether astringents ever check to ad- 
vantage the waste of albumen through the kidneys. If any be 
worth the trial, it is ammonio-ferric alum. Counter-irritants 
over the kidneys, unless of the mildest character (tinct. iodin., 
emplastr. picis, etc.), will not do any important good in chronic 
Bright' s disease. 

For the dropsy, warm baths and hydragogue cathartics are 
advised. Of the latter, cream of tartar and jalap, together, 
are the favorites : 2 to -3 drachms of the bitartrate with 10 to 
20 grains of jalap two or three times a week. If serious 
dropsical accumulation threaten life, elaterium (gr. | or $ 
every four hours, in pill, till it acts) may be given. But it is 
a decided mistake to harass the patient constantly with 
exhausting purgation. It is to be remembered that it can act 
only as a palliative, removing part of the effects of the malady, 
not the disease itself. 

If the warm bath do not agree, or fail to produce diaphore- 
sis, those who have access to it should try the hot air bath at 
130° to 150° Fah. This rarely fails to produce/free perspira- 
tion. For weaker invalids, the vapor bath is available. 

Of diuretics, acetate of potassium, spirit of nitrous ether, 



DIABETES MELLITUS 315 

and infusion or compound spirit of juniper will be least likely 
to disappoint. But all will not unfrequently fail. 

Then we have as a resource (where tapping for ascites is 
not demanded) for the relief of great oedema, the use of incis- 
ions with a lancet, or needle, in the swollen legs and feet. 
Some prefer a number of small incisions with an abscess 
lancet plunged through the skin of the calf and dorsum of the 
foot. It is possible that erysipelas may follow ; but this 
danger will be lessened by repeated warm sponging of the 
limbs, washing them with diluted glycerine, inunction with 
lard, cold cream or vasoline, which is best. 

The complications of Bright's disease must be treated 
according to their own indications, on general principles — 
bearing in mind always the degenerative and asthenic tendencies 
belonging to the malady. 

Diabetes Mellitus. 

Synonym. — Glycosuria. 

Definition. — Excessive urination, with the presence of 
sugar in the urine. 

Causation. — Twice as many men as women have this 
disease. It is most frequent among young and middle-aged 
adults; the mortality from it being greatest from fifteen to 
fifty-five. It is more common in cities and manufacturing 
districts than in the open country. Occasionally it is heredi- 
tary. 

Exciting causes appear to be, exposure to cold and wet ; 
drinking cold water largely when heated; excessive use of 
saccharine food ; intemperance ; violent emotion ; febrile 
diseases ; and organic affections and injuries of the brain and 
spinal cord. 

Symptoms and Course. — Beginning insidiously, with 
malaise and slight loss of flesh, urination becomes excessive, 
with corresponding thirst, and very often bulimia or excessive 
appetite ; emaciation is progressive ; the skin harsh and dry ; 
the tongue, glazed and furrowed, the mouth clammy; the 



316 DIABETES MELLITUS. 

sexual and mental powers fail by degrees. Lastly, hectic 
fever, oedema of the limbs, diarrhoea, and often all the symp- 
toms of pulmonary consumption terminate the case. 

Complications. — Tuberculization of the lungs occurs in 
nearly half the cases of diabetes mellitus which last over a 
year or two. Inflammations of an asthenic type are common 
in all the organs. Boils and carbuncles are very frequent. 
Gangrene of the lower extremities has been several times 
observed. Amblyopia (obscure vision) is present in about 
one-fifth of the cases. Cataract generally forms in cases of 
long standing ; but may be absent altogether in those of less 
than two years' duration. 

Diagnosis. — The detection of sugar in the urine, not tem- 
porarily, but for a considerable time, is of itself sufficient to 
make out the case. (See Chemistry.) 

Prognosis. — Recovery is not impossible in diabetes ; but 
a large majority of cases end in death. Amelioration — keeping 
the disease in abeyance — is often an attainable end. The 
younger the patient in whom the disorder begins, the less 
ultimate hope. In old persons glycosuria seems more often 
compatible with tolerable health for a long time. Cases 
traced to mental emotion or to injuries are somewhat more 
hopeful than those of indistinct origin. 

Amblyopia, cataract, and albuminuria, as well as phthisical 
symptoms, mark the case as incurable. Considerable diminu- 
tion of the sugar, or of the water, passed, is always a favorable 
prognostic. But the diabetic patient is much more liable 
than others to those inflammatory complications which, on 
-slight exposure, may hasten the termination of life. 

Treatment. — No direct control over the sugar-forming 
process in the body has yet been obtained by medicine. But, 
although it would seem that simply diminishing the formation 
of sugar by withholding material for it ought not to be 
expected to do much good, it does prove beneficial. The 
most important measure yet devised in the management of 



CYSTITIS. 317 

diabetes is, the prohibition of sugar and starch, and of every- 
thing which can yield them, as food. Bread, except bran 
bread, which is almost free from starch, potatoes, and nearly 
all vegetables and fruits must be excluded. The safe excep- 
tions are, the cabbage, broccoli, onions, spinach, celery, and 
lettuce. Of animal diet, milk and liver are forbidden articles. 
All meats, eggs and butter, and jellies are allowable. Gluten 
bread may be made on Bonchardat's plan, without starch, in- 
flated by machinery with carbonic acid or compressed air. 
Tea or coffee may be sweetened with glycerine (chemically 
pure, as Bower's or Price's. Spirits, wines, and beer should 
be avoided unless called for by positive weakness; if that 
exist, the least saccharine should be preferred, as sherry, 
claret, or whisky, in minimum quantities. There is no 
advantage in restricting the amount of water taken to quench 
thirst. Variety of diet, of course, within the prescribed 
limits, is important, to prevent disgust and loss of appetite. 

Of medicines, none have been yet shown to do much service 
in checking the disease. The most positive influence in di- 
minishing the diuresis belongs to opium ; but this does not 
appear to interfere with the progress of the disease. Various 
drugs have been tried, and lauded greatly by different users ; 
but their effects will not bear scrutiny without disappoint- 
ment. Among them the most prominent are alkalies, yeast, 
rennet, pepsin, iron, quinine, creasote, alum, iodine, nitric 
acid, turpentine, and the inhalation of oxygen. The free 
ingestion of sugar has been freely experimented with, but 
in vain. A therapeutic remedy for diabetes remains to be 
discovered. 

Cystitis. 

Definition. — Inflammation of the bladder. 

Varieties. — Acute and chronic ; idiopathic, traumatic, 
secondary. 

Causation. — Wounds, bruises, or other injuries; the 
presence of gravel, or a calculus, or hydatid vesicles from the 



318 CYSTITIS. 

kidney; irritating diuretics; or decomposing urine retained 
by stricture, may induce acute cystitis. The continuation 
or frequent repetition of the same causes produces " chronic 
inflammation." 

Symptoms: Acute Cystitis. — Pain in the vesical region; 
frequent desire to pass water, with burning in the urethra, and 
tenesmus, or disposition to bear down or strain. There is 
fever, alternating with chills. The bladder may sometimes be 
felt as a small round swelling, sensitive upon pressure. In 
bad cases, there arenausea, anxiety, delirium, and cold 
perspiration; the scantily passed urine becomes purulent and 
bloody, alkaline and fetid. 

Chronic Cystitis has usually much less severity of symptoms; 
but it may be very distressing from the tenderness and 
irritability of the bladder, and the frequent disposition to 
urinate, with dysuria. The urine is either mucous or muco- 
purulent. 

Teeamext. — Acute cystitis, perfect rest and a saline 
laxative or castor oil is apt to be the best. Warm hip 
baths will ■ be very soothing. Flaxseed tea may be 
taken freely. Opium, hyoscyamus, chloral, or belladonna 
may be called for by great pain or nervous irritability. 
Opium or belladonna suppositories or laudanum enemata, 
will answer best if anodynes have to be repeated often. 
In chronic cystitis, the other measures named may be suit- 
able from time to time ; also injections of lime-water and 
glycerine, or weak solution of nitrate of silver, or of sul- 
phate of copper, or acetate of lead, in water or glycerine, 
may be serviceable. Catheterism may at times be .indispen- 
sable, both in acute and chronic cystitis; but it should be 
avoided if possible, on account of the mechanical irritation 
of the instrument. A soft catheter is the best. 



DISEASES OF THE RESPIRATORY ORGANS. 319 

CHAPTER VIII. 

DISEASES OF THE RESPIRATORY ORGANS. 

Pneumonia. 

Definition. — Inflammation of the substance of the lung. 

Varieties. — According to its seat; single, double, lob- 
ular. According to causation; idiopathic, from cold and 
wet; traumatic, from injury; tuberculous, in phthisis; and 
typhoid pneumonia. 

Symptoms and Course. — A chill or stage of depression, 
followed soon by fever, with oppression in breathing, dull 
pain (not always present) in the chest, and sometimes short 
cough. Delirium is common. Temperature of the body 
high, especially on "the fourth or fifth day ; sometimes, in 
the evening, reaching 104° or 105° Fahr. in the axilla. 
Secretions scant, as in other febrile states. Urine containing 
an excess of urea, but deficient especially in the chlorides, in 
the middle period of the attack. Expectoration commences 
about the third day usually, the sputa being composed of 
mucus, lymph, and blood mixed together, making the rusty 
sputum of pneumonia. 

The height of the attack is generally reached between the 
fifth and seventh day ; after which the temperature declines, 
and, in favorable cases, all the symptoms subside. In others, 
oppression in breathing, and prostration increase ; cough 
deepens, and expectoration becomes more abundant, at last 
purulent. Death seldom occurs before the sixth, and may 
be as late as the twentieth day. 

Stages. — 1. That of congestion or engorgement, and the 
commencement of exudation. 2. That of exudation and red 
hepatization. 3. That of gray hepatization, softening or 
purulent infiltration. 

Physical Signs. — These differ in the three stages. In 
the first they are, moderate dullness of resonance on per- 



320 PNEUMONIA. 

cussion over the affected lung, and, on auscultation, after 
the first day or two, the fine crepitant rale. 

In the second stage, decided dullness on percussion, no 
rale, but, instead, bronchial respiration and bronchophony; 
with increased vocal fremitus. In the stage of softening or 
suppurative infiltration (gray hepatization), dullness on per- 
cussion, and coarse crepitant or mucous rale. 

"When resolution follows the second stage, as in most cases 
of recovery, the bronchial respiration gives way to returning 
fine crepitation (crepitus redux) ; and then the dullness of 
resonance on percussion also generally disappears. 

Terminations. — Resolution; death in the second stage 
from asphyxia; death from exhaustion in the third stage; 
recovery after the third stage (uncommon); abscess ; gangrene 
of the lung. 

Morbid Anatomy. — The lower or iddme lobe is almost 
always the seat of the disease. Should death take place (as it 
rarely does) in the first stage, the lung would be found some- 
what sw T ollen, dark-red, inelastic (splenization), and filled with 
blood or bloody serum. It will still float in water, though 
heavier than healthy lung. It is easily torn. 

In the second stage, of hepatization, the lung is no longer 
spongy, but presents considerable resemblance to the liver; 
although a finger may be easily thrust through it. When 
entirely hepatized, it will not float in water, the air being 
displaced from the cells by the exudation of coagulable 
lymph. 

The third stage consists in the degeneration (in the absence 
of more favorable resolution by absorption) of the exudation. 
This occurs by granulation, softening and suppuration. Mostly 
the latter is infiltrated; occasionally an abscess forms. In 
gray hepatization, the lung is solid, impermeable to air, with a 
granite-like appearance of red and white points on section. 
It sinks in water, but is more easily torn or crushed into a 
pulp than in the second stage. 

Diagnosis. — The only affections with which pneumonia is 



PNEUMONIA. 321 

likely to be confounded are pleurisy, bronchitis, and phthisis. 
In children, collapse of the lung has been mistaken for lobu- 
lar pneumonia. 

From pleurisy, it is known by the absence of the sharp 
pain belonging to the latter, and by the crepitant rale and 
rusty sputa. From bronchitis, by the dullness on percussion, 
rale, bronchial respiration, and bronchophony. From phthisis, 
by its sudden onset, fine crepitation, and sputa, as well as by 
the acute violence of the attack. Latent pneumonia some- 
times complicates fevers, etc. 

Prognosis. — Simple pneumonia, of one lung, in a young 
and previously healthy person, ought, under favorable circum- 
stances and judicious treatment, always to be recovered from. 
In the aged, it is dangerous ; and double pneumonia is so at 
all periods of life, though good recoveries do occur. It is 
double in about one case in eight. 

Among the unfavorable signs — most of which are obvious 
— are expectoration of pure blood in the first stage, and 
albuminuria in the second. 

Treatment. — An emetic, followed by a cathartic, is usu- 
ally proper to begin with. 

The early administration of a purgative, as Epsom salts or 
citrate of magnesium, is proper, in the absence of any special 
contraindication. A water pack on the chest or hot fomenta- 
tions do good. 

The hot skin, hard or oppressed pulse, pain and dyspnoea, 
and more or less darkly flushed face, require small doses of 
aconite or veratrum, followed by ipecacuanha or nitrate of 
potassium, gr. x, every two hours. Some prefer acetate of 
potassium. 

Asthenic pneumonia requires a different treatment; and 
the same will apply to the third or suppurative stage of all 
cases. Support may be required, in a few cases, even from 
the first; by beef-tea, wine, or spirits (best with nourishment, 
as in punch), quinine or ammonia. In hospital, some cases 

24* 



322 PLEURISY. 

may recover under this plan alone; but they are the exceptions. 
Beef-tea in the second stage, and quinine later. A large 
blister over the affected part is generally useful about the 
fifth, sixth, or seventh day of the attack. 

Typhoid pneumonia is a term not always uniformly applied „ 
It means, sometimes, or with some authors, inflammation of 
the lungs complicating typhoid fever ; others include under it 
all cases of asthenic pneumonia. More generally, however, it 
designates that form of the disease in which epidemic or 
endemic influence has impressed a peculiar character. Malarial 
regions especially exhibit this, in the "winter fever" or 
typhoid pneumonia of our Southern States. Early and great 
debility, out of proportion to the local symptoms, with a ten- 
dency to low delirium, and to remittence, mark this disorder. 
In treatment, it bears- no depletion, hardly the reduction of 
excitement by a sedative. Diaphoretics first, as ipecac, one 
grain, alternated with five or ten grains of nitrate of potassi- 
um, every three hours; or liquor ammonii acetatis, or solu- 
tion of acetate of potassium ; then quinine, when the need of 
a tonic is apparent, which may be very early ; with strong 
liquid nourishment, and moderate counter-irritation; these 
are the measures usually proper in typhoid pneumonia. 

Pleurisy — Inflammation of the Pleura. 

Varieties. — Single or unilateral, and bilateral or double ; 
idiopathic, traumatic, and secondary, as tuberculous, cancerous*. 

Symptoms and Course. — Generally, after a chill or cold 
stage, sharp pain in the side, impeded and accelerated respira- 
tion, short, sharp cough, and fever. The pain centres in the- 
infra-mammary or lower axillary region ; it is often intense, 
and is increased by a long breath, by coughing, pressure, or 
lying on the affected side. The pain and fever lessen after 
effusion has occurred ; but the dyspnoea may then be increased. 
It is, after that period, most comfortable to lie on the 
diseased side, so as to allow of free breathing by the other 
lung. Acute pleurisy is often recovered from without anv 



PLEURISY. 323 

considerable effusion. When the latter does occur, absorp- 
tion mostly follows. If not, life is endangered by interference 
with respiration. At first serous, constituting one form of 
hydrothorax, the fluid may become purulent; this is empyema. 
The term false empyema is sometimes given to a collection of 
pus in the pleural cavity from the rupture of an abscess in the 
lung. Pneumothorax is the accumulation of air in the cavity 
of the pleura ; hydro-pneumothorax, of water and air together. 
Both of these are most common in tuberculous pleurisy, i. e., 
in the course of a case of pulmonary phthisis. 

Stages. — In severe pleuritis there may be, 1, the adhesive; 
2, the effusive; 3, the suppurative stage. In more favorable 
cases the 3d stage is that of absorption. 

Physical Sigxs. — Of the 1st stage, deficient elevation of 
the ribs in breathing, feeble respiratory murmur on the 
affected side, and friction sound. 2d stage, dullness of reso- 
nance on percussion, bronchial respiration, bronchophony, 
sometimes wgophony. When the effusion becomes very copi- 
ous, bulging of the side occurs, suppression of respiratory 
sound and of vocal resonance and vibration, with exaggerated 
or puerile respiration on the sound side. Displacement of the 
heart may^take place if it is on the left side; of the liver if on 
the right. There is no physical sign by Avhich empyema can 
be distinguished from serous effusion; but irritative fever 
usually accompanies empyema. 

Absorption following extensive effusion allows retraction 
and depression of the chest on that side, from the slow or 
imperfect expansion of the lung. Then return, first, bronchial 
respiration and voice, or segophony, and gradually the normal 
respiratory murmur. Sometimes, from adhesions of false 
membrane over the lung, permanent depression of the thorax 
on that side is left. 

During effusion, its fluid character as well as extent may be 
shown by percussion in different positions. Sitting up, it falls 
forward, and rises to a higher line in front; lying on the back, 
the dullness, from gravitation, may fill much lower in the 



324 PLEURISY. 

anterior region. Sometimes adhesions prevent this. Succus- 
sion, or sudden shaking of the chest of the patient, may 
produce an audible splashing, if the ear be over or near the 
affected side. By ocular inspection and measurement, the 
changes in the amount of the effusion may be estimated from 
time to time. 

Morbid Anatomy. — In the early period, general redness 
and vascular injection of the pleura, with bands of whitish and 
more or less translucent or opaque coagulable lymph, causing 
adhesions of the pulmonary and costal pleura. Later, serous, 
sanguinolent or purulent effusion, in variable quantity, and 
sometimes displacement of the heart, lungs, and liver, and 
bulging of the ribs and intercostal spaces. 

Diagnosis. — From pneumonia, pleurisy is known in the 
height of the acute attack by the sharpness of the pain, the 
friction sound, and absence of crepitant rale and of dullness on 
percussion. After effusion, especially by the change of the 
line of dullness with change of position, sitting and recumbent ; 
by the bulging ; and the degree of diminution of vibration of 
the walls of the chest when speaking. 

From intercostal neuralgia, pleurisy is distinguished by the 
absence of fever and friction sounds in the former, and the 
non-increase of the neuralgic pain upon inspiration. Conges- 
tion, in some rare cases, attends neuralgia; the diagnosis is 
then more difficult. In intercostal muscular rheumatism, 
there is slight increase of pain in breathing deeply, but as 
much in moving the arms ; and the pain is much less acute, 
and generally without fever. 

Prognosis. — Pleurisy is rarely fatal; though death may 
occur, from very abundant effusion in bilateral pleuritis, or, 
with empyema in the unilateral, through gradual exhaustion. 

Causation. — Exposure to cold and damp is the ordinary 
exciting cause of "idiopathic" pleurisy. Fracture of the rib, 
punctured wounds, etc., may cause traumatic pleurisy. In 
the course of phthisis, it not uncommonly occurs by extension 



ABSCESS OF THE LUNG. 325 

of the disease from the lung. Cancer of the chest may pro- 
duce it in an analogous manner. 

Treatment. — An emetic, followed with a free purge. 
Then give ipecac 2 J grs. to 1 gr. of opium every two or three 
hours till the pain subsides, which will suffice in most cases, if 
sinapisms or hot fomentations are industriously applied to the 
chest at the same time; also, hot and moist appliances to the 
feet, to induce free general perspiration. This antidotes the 
cause— a sudden cold. Carefully avoid narcotism, and if the 
pain continues, a large blister should be applied over the part 
affected, which usually brings entire relief. 

For the effusion, diuretics, as squill, juniper berry infusion 
or compound spirit, acetate or bitartrate of potassium, etc., 
may be used. Iodine, in LugoPs solution, and iodide of 
potassium alone, are often advised. Repeated blistering some- 
times has excellent effect. 

When life seems to be threatened by exhaustion from 
dyspnoea, owing to large effusion not becoming absorbed, 
paracentesis, or puncture of the chest, is proper. Dr. Bow- 
ditch's plan is the best for this. He uses Dr. Wyman's 
apparatus, which is a trocar, with a silver canula having a 
stopcock, and capable of being connected with a syringe by an 
intermediate piece, also haviug a stopcock, both cocks acting 
the same way. The operation is performed while the patient 
is sitting up, if able, or lying over the edge of the bed. The 
puncture is made somewhere between the seventh and tenth 
ribs, just behind their angles; making sure first of the posi- 
tion of the liver and spleen, so as to avoid them. Dieulafoy's 
pneumatic aspiration has been recently found to be an avail- 
able method in thoracentesis. 

In chronic cases of pleuritic effusion or empyema, the 
strength of the patient requires to be supported by good diet, 
and sometimes by tonics. This, in empyema, is often the 
most important part of the treatment. 

Abscess of the Lung. 

In rare instances, inflammation of the lung, active or 



326 PULMONARY GANGRENE. 

latent may terminate in abscess. Before rupture, dullness on 
percussion, bronchial respiration, and dyspnoea proportioned 
to the size of the abscess, are present. When an opening 
occurs, allowing the matter to escape into the bronchial 
tubes, the rather sudden commencement of purulent expec- 
toration should attract attention. Then the physical signs 
of a cavity are discovered by percussion and auscultation ; 
amphoric or tympanitic resonance on percussion, cavernous 
respiration, metallic tinkling, etc., varying with circum- 
stances. As is the case with pleuritic empyema, pulmonary 
abscesses may communicate externally by a spontaneous 
opening. 

The principal importance of abscess of the lung consists 
in the possibility of mistaking it for phthisis. The points 
of difference will be alluded to in connection with that 
disease. 

Pulmonary Gangrene. 

This may occur in pneumonia from extreme violence of 
the inflammation, or from a depressed state of the system ; 
also, from cancer within the chest, pyaemia, etc. It is rare, 
but more common than circumscribed abscess of the lung. 
Unless very narrowly limited, pulmonary gangrene is always 
fetal. Its signs are, coarse mucous rale, taking the place of 
the vesicular murmur in the lower part of the lung, with 
copious brownish and offensively fetid expectoration, dysp- 
noea, and great prostration. 

In bronchitis, occasionally, temporary fetor of the expec- 
toration and breath may simulate gangrene; but transiently, 
and without the above symptoms. 

The treatment of pulmonary gangrene must be, of course, 
supporting and antiseptic. Alcoholic stimulants, rather 
freely given, will be proper, with concentrated liquid food, 
as beef-tea. Sulphite ' of sodium (ten grains in solution 
every three hours) may be tried; or chlorine water, a tea- 
spoonful or two every two or three hours. 



emphysema of the lung, etc. 327 

Emphysema of the Lung. 

This is dilatation of the pulmonary air-cells of one or 
both lungs. It may accompany prolonged asthma, or may 
follow chronic bronchitis. Its symptoms are, dyspnoea, and, 
when extensive, blueness of the lips, cyanosis, from interference 
with the circulation through the lungs ; in many cases wheezing 
respiration. The physical signs are bulging of the chest, 
increased clearness of resonance on percussion, and feeble 
inspiratory murmur with prolonged expiratory sound; some- 
times displacement of the heart or liver. It is most easily 
mistaken for pneumothorax. But, in the latter, the reso- 
nance on percussion is more tympanitic, the inspiratory mur- 
mur still feebler, or quite absent, and there is no prolonged 
expiratory sound ; besides which, the concomitants of pneu- 
mothorax are usually too severe to distinguish it. 
Collapse of thg Lung. 

In whooping-cough or in severe bronchitis, especially in 
children, obstruction of a considerable air-tube may lead to 
an exhaustion of air from the cells supplied by it, and a 
return of that portion of the lung to the unexpanded con- 
dition (atelectasis) of foetal life. The same state may accur 
in other conditions, from debility. It was formerly always 
mistaken for lobular pneumonia. It is usually fatal, unless 
very limited. 

Bronchitis. 

Varieties. — Acute and chronic ; general, capillary ; plas- 
tic, rheumatic, and syphilitic bronchitis. 

Symptoms and Course. — Systemic depression, followed 
by fever ; tightness and soreness of the upper and anterior 
part of the chest ; cough, at first short, dry, and tight ; 
later, deeper and looser, with expectoration ; the latter being 
at first mucous, in rare instances pseudo-membranous, in 
severe cases at a' late stage purulent. 

Capillary bronchitis is ^marked by great dyspnoea and 
tendency to early depression and prostration. 



328 BRONCHITIS. 

Chronic bronchitis is often free from febrile symptoms, 
the cough and expectoration, with slight dyspnoea, character- 
izing it. 

Physical Signs. — JSTo dullness on percussion, except in 
case of collapse of part of a lung from obstruction; sonorous 
rhonchus and sibilus, generally, though not quite always, on 
both sides of the chest; varying from time to time, in seat, 
character, and loudness. In capillary bronchitis, extended 
mucous, crepitant, or subcrepitant rales, closely resembling 
the fine crepitation of pneumonia. 

Diagnosis. — No difficulty exists except in distinguishing 
chronic bronchitis from phthisis. Absence of dullness on 
percussion and of the signs of excavation, are most important ; 
the expectoration also is whiter and of less weight in bron- 
chitis ; and there is no hectic fever. 

Prognosis. — Acute bronchitis is dangerous in old persons 
and young children; seldom fatal in vigorous middle life. 
The capillary form is always most serious, death taking place 
sometimes from the 10th to the 12th day. Chronic bronchitis 
is not often fatal, even by exhaustion; but it may last an 
indefinite time, even many months. 

Treatment. — Abortive treatment of a " cold on the chest " 
may sometimes be effected within the first twenty-four hours, 
by taking, at bedtime,. a glass of hot lemonade or ten grains 
of Dover's powder after a warm mustard foot-bath. Should 
this fail or be omitted, a brisk saline purgative should be 
given, of Epsom or Pochelle salts, or citrate of magnesium. 
Then, when the fever is high, cough very tight, and breast 
sore, the ipecacuanha in nauseating doses given every 
two or three hours, with frequent draughts of flaxseed tea or 
some similar demulcent. A large sinapism over the upper 
sternal region will aid in giving relief; and so will friction 
with oil of turpentine, and hot fomentations. - 

In milder cases, or where the strength of the stomach is 
doubtful, syrup of ipecacuanha, i to J drachm every two or 
three hours, will answer ; and it should be continued until the 



ASTHMA. 329 

cough softens and the breathing becomes easier. Then syrup 
of squills may follow, in fliiidrachm doses, every three or four 
hours. When the cough is troublesome at night J to 1 
fluidrachm of paregoric may be added at bedtime ; or through 
the day, occasionally, if coughing be very violent or frequent. 
Opiates do the most good, however, after some loosening of 
the cough with free expectoration. When the fever has 
abated, and especially if dyspnoea continue, a blister may be 
applied over the sternum. 

In capillary bronchitis, or in the ordinary form in the aged 
and feeble, the more stimulating expectorants maybe required, 
as senega, in decotion or syrup, chloride or carbonate of am- 
monium, with quinine and beef-tea, wine-whey, or whisky- 
punch. Inhalation of steam, alone, or from infusion of hops, 
sometimes soothes the air-tubes advantageously. 

Chronic bronchitis requires persevering use of counter- 
irritation over the chest, painting with tincture of iodine, 
plaster of Burgundy pitch, hemlock, etc., an alternation of 
stimulating and alterative expectorants, and tonics. Besides 
squill and senega, ammoniacum, copaiba, and chloride of 
ammonium are most frequently useful. If the system be 
below par, quinine, iron, and cod-liver oil are important. 
When secretion is very copious, inhalation of tar-vapor 
or of creasote should be tried. The former may be used by 
putting an ounce or two of tar in a cup over boiling water, so 
as to diffuse the tar-vapor through the chamber. Creasote, 
20 or 30 drops, may be put into half a pint of boiling water, 
to be breathed by means of an ordinary inhaler. When 
medicine fails, change of air will sometimes entirely cure. 

Asthma. 

Definition.— Paroxysmal and spasmodic dyspnoea. 

Varieties — Idiopathic and symptomatic ; dyspeptic asthma ; 
hay asthma. 

Symptoms and Course. — Every night, or once a week, 
month or year, or at irregular intervals, the attack comes on. 



330 ASTHMA. 

Most frequently it is between 1 and 3 o'clock in the morning. 
Premonitory symptoms often are great drowsiness, or wakeful- 
ness, headache, flatulence, itching under the chin. Dyspnoea is 
then the characteristic symptom. The sufferer sits or stands up, 
leaning forward, and labors to breathe. The chest is expanded 
to its utmost, by the accessory as well as principal inspiratory 
muscles. The countenance is anxious, with pallor, coldness, 
and in severe cases lividness, of the face and hands. Perspi- 
ration is often copious. A wheezing sound accompanies 
respiration ; giving way finally, with relief, upon the expector- 
ation of mucus, usually rather thick, and in pellets. 

The attack may pass over in a few minutes, or may last for 
hours, or, with some remission, days or weeks. Where 
asthmatic symptoms are persistent, as is not very uncommon, 
for years, some structural change in the organs of the chest 
exists; it is then symptomatic asthma. 

Physical Signs. — Inspection shows unusual elevation of 
the ribs and shoulders. Placing the ear on the chest, sonorous 
and sibilant sounds, loud but mostly small in calibre, are 
found to take the place of the respiratory murmur. These 
sounds change their locality frequently. As the attack gives 
way, with expectoration, some mucous rale is heard. 

Special exploration is necessary in each case to determine 
the presence of pulmonary or cardiac complications. 

Prognosis. — Death almost never occurs during the fit of 
asthma. 

Those subject to it often live to old age. But dilatation of 
the pulmonary air-cells, and enlargement of the heart, may 
follow in protracted cases, breaking down the health. 

Pathology and Nature. — It has been made certain that 
asthmatic dyspnoea is owing to a spasmodic constriction of the 
smaller bronchial tubes, by tonic contraction, mostly reflex, 
of their involuntary muscular fibres. 

Causation. — Asthma is hereditary in a majority of cases. 
Males have it more often than females. It may occur at any 
age. 



ASTHMA. 331 

Treatment. — During the attack, our aim must be to give 
relief, by relaxing spasm. An emetic, then ipecacuanha wine, 
with tincture of lobelia, one-quarter to one-half fluiclrachm of 
each every half-hour until nausea or expectoration is pro- 
duced, I have known often to act well. Hoffmann's anodyne, 
in one-half drachm or drachm doses, will sometimes do great 
good ; and so may hydrate of chloral, in doses of from twenty 
to forty grains. Some practitioners advise hyoscyamus, musk 
and hydrocyanic acid. Smoking tobacco is relieving in some 
instances ; smoking cigarettes of stramonium leaves, in others. 
More still find comfort in breathing the air in which are 
burned papers which have been soaked in a saturated solution 
of nitrate of potassium. Inhalation of ether or nitrous oxide 
may be carefully used in extreme cases. As an adjuvant, the 
warm mustard foot-bath may be employed, as well as sina- 
pisms or dry cupping between the shoulders. 

Between the attacks, endeavor should be made to rectify 
digestion and its tributary processes, and to invigorate the 
nervous system. Some cases will require podophyllin, nitro- 
muriatic acid, or taraxacum, bitter tonics and mild laxatives, 
such as rhubarb, etc. Others need iron and quinine. Iodide 
of potassium is highly recommended by some; conium, canna- 
bis indica, and arsenic in small doses by others. There is 
reason for giving trial to the bromide of potassium in obstinate 
cases; most patients will bear from 10 to 20 grains of this 
twice or thrice daily for weeks together without inconvenience. 

Prophylaxis. — No disease is more curiously capricious in 
its causation than asthma. Some always have a paroxysm if 
they visit the sea-shore; others are more secure there than 
elsewhere. One cannot sleep on the first floor ; another does 
better there than higher up. Each must learn his own 
peculiarities, and be governed accordingly. 

Most remarkable are the annual attacks of hay asthma, 
summer catarrh, or asthmatic bronchitis, to which a few 
individuals are subject. 



332 BRONCHIAL DILATATION — LARYNGITIS. 

In asthmatic persons generally, nothing is more important 
thag prudence and regularity in diet, regimen and habits. 

Bronchial Dilatation. 

In this, extreme degrees are not common; it is of interest 
chiefly because it is possible for it to be mistaken for phthisis. 
There are two forms; the tubular and the saccular enlarge- 
ment. 

In either, slight dullness on percussion may occur, from 
condensation of the lung around the expanded part. Sonorous 
rhonchus and coarse mucous rale exist, the latter especially in 
the saccular form. In this, the signs are almost identical 
with those of tubercular excavation; but they occur usually 
at the middle or lower part of the lung, and are stationary, as 
they are not in tuberculization. 

The cough is very troublesome, and attended by copious 
mucous or slightly purulent expectoration, is common in 
bronchial dilatation. The palliation of this symptom, with 
care of the general condition of the patient, is all that can be 
accomplished for it in treatment. 

Laryngitis. 

Slight inflammation or congestion of the mucous membrane 
of the larynx is very common as the result of cold ; its signs 
being hoarseness, with a dry, short, harsh cough, and some 
soreness in drawing a breath. But simple acute laryngitis of 
severe grade is quite a rare affection. 

When it occurs, there is fever, with hoarseness, "brassy" 
cough, distressing dyspnoea, and difficulty of swallowing. 
(Edema glottidis, or submucous effusion of serum, constitutes 
the greatest danger in laryngitis; the swelling, obstructing 
respiration to a degree often fatal. This disorder is almost 
exclusively met with in adults. 

Early purging, counter-irritation, the internal use of ipecac, 
in doses just short of nausea, with moderate quantities of 
opium, and the frequent inhalation of the steam of boiling 
water, constitute the best treatment. If dyspnoea becomes 



THE LAKYNGOSCOPE. 333 

decidedly serious, threatening asphyxia, tracheotomy is 
advised. Some account of this operation will be given in 
connection with Croup. 

(Edema of the glottis may be produced immediately by the 
ingestion of boiling water, or of sulphuric or nitric acid. 
This has often accidentally happened. 

Chronic laryngitis, with ulceration, is a not infrequent 
attendant of phthisis. Some cases of the latter begin with it; 
in others it occurs somewhat late in the course of the disease. 
Syphilitic ulceration of the larynx is tolerably common, as a 
secondary symptom. This, as well as polypi or other tumors 
of the larynx, may be discovered, and treated by operation for 
removal, or with solutions of nitrate of silver, etc., with the 
aid of the laryngoscope. 

The confidence of many physicians in the utility of very 
strong solutions of nitrate of silver in chronic inflammations of 
the mucous membranes, of the throat or elsewhere, has not 
increased, in fact has not been sustained, by what has been 
seen in practice. Dr. Horace Green and others have made 
frequent use of it of the strength of sixty grains to an ounce. 
Except for ulceration, which may benefit even by the solid 
caustic, from four to ten grains in the ounce of water will do 
more good, in almost all cases, than the stronger proportions. 

The application of nebulized liquids, by apparatus for 
atomization, is now much in vogue in both acute and chronic 
laryngitis. Some remarks upon this will be made hereafter. 

The Lakyngoscope. 

The apparatus required for laryngoscopy consists of a 
laryngeal mirror, an illuminating mirror, and a tongue- 
depressor. Glass or polished metal may do for the mirrors. 

The laryngeal mirror may be round or square, preferably 
the former ; and about an inch or less in diameter. It should 
be attached at an obtuse angle (120° to 125°) to a stem, which 
may be fastened into a slender handle so as to be drawn out 
or pushed in. 



334 APHONIA LOSS OF VOICE. 

The illuminating mirror is larger (from 3 to 12 inehes in 
diameter) and concave, to concentrate reflected light. It may 
be held by a handle in the operator's mouth, or fixed by a 
band to his forehead, or, best, as used by Semeleder, perforated 
in the middle and fastened so the bridge of a pair of spectacles 
(with or without the glasses) so as to rest before one of the 
eyes and be looked through. 

The laryngeal mirror is introduced (after being warmed to 
prevent condensation of moisture) so that its back pushes the 
uvula upwards and backwards, its lower edge presses upon the 
posterior wall of the pharynx, and its stem rests in the angle 
of the mouth. 

Sunlight, horizontal (morning or evening), is the best for 
laryngoscopy, but artificial light, as of a good lamp, may 
suffice. 

The diffHeulty of the operation is produced by the irritabil- 
ity of the fauces and larynx. Few can allow of a successful 
examination on the first attempt; practice makes tolerance. 
To hasten this, bromide of potassium has been given by some. 
The frequent insertion and retention for a while of the finger 
of the patient, or of an instrument, in the fauces, accustoms 
the parts to pressure. Holding ice in the throat just before 
the examination also lulls sensibility. 

By laryngoscopy, tumors, ulcerations, inflammatory 
changes, etc., in the larynx may be inspected, topical applica- 
tions, as of nitrate of silver, made, and surgical operations 
performed, with a precision not otherwise possible. 

Khinoscopy is the examination, in a similar manner, of 
the posterior nares. It requires merely a smaller mirror (less 
than three-fourths of an inch in diameter) than for laryn- 
goscopy, and at about a right angle to its handle. 
Aphonia — Loss of Voice. 

Loss of voice may be transient or permanent; and either 
functional or structural in its origin. Especially in hysterical 
females, a nervous shock may produce a paresis or enfeeble- 
ment of the vocal power, lasting often for days together. 



LARYNGISMUS STRIDULUS. 335 

Faradization, i. e., the use of induced electrical currents (as 
magneto-electricity) , carefully applied, has sometimes cured 
nervous or hysterical aphonia. Vesication of the back of the 
neck may be useful ; improve the general health. 

Congenital dumbness, except in idiots, is due to deafness, 
making the learning of speech impossible, unless by a recently 
invented system of instruction by sight. 

Organic or structural aphonia is caused by lesions of the 
larynx, such as ulcerative destruction of the vocal cords, 
tumors, etc., which are to be diagnosticated by laryngoscopy. 

The term dysphonia clericorum has been applied to an affec- 
tion of the throat not uncommon among clergyman and other 
public speakers, " follicular disease of the pharyngo-laryngeal 
membrane." 

A conventional treatment for this affection has been the 
application every day or two of a solution of nitrate of silver, 
with a brush or probang. Saturated solution of tannin is also 
used for it. If these local remedies do not relieve in a week 
or two, the frequent swallowing of small pieces of ice, or gen- 
tle gargling several times a day with ice-water, may be sub- 
stituted with advantage. Counter-irritation of the throat 
should, if necessary, b© persevered in for a considerable time. 
Three drops of croton oil (diluted with as much sweet oil for a 
delicate skin) may be rubbed over a limited space in front of 
the throat every night until a papular eruption comes out.* 

Many cases of this complaint are as much constitutional as 
local in origin. Where real dysphonia (difficulty or imperfec- 
tion of vocalization) exists, public speaking or singing must 
be avoided to allow the organs repose. Tonics and change of 
air may often prove the best measures of treatment ; every 
means to improve the general health. 

Laryngismus Stridulus. 

This is an infantile affection, consisting in spasmodic 

*Patients should be cautioned, of course, against allowing the oil to 
come near the eyes. I have known a severe ophthalmia to result from 
neglect of this. 



336 ceoup. 

closure of the glottis, causing a stridulous or shrill ' whistling 
respiration. It is more apt to occur during dentition, but is 
not very common. Its onset is sudden, and duration brief. 
Though exceedingly alarming, it is seldom fatal. 

The treatment must be prompt ; applying a sponge wrung 
out of hot water to the throat, and putting the feet into hot 
water, to produce derivation and diffusive stimulation. In 
severe cases mustard plasters (diluted with flour) may be 
applied to the chest and back. Some advise the momentary 
inhalation of ether or chloroform. When life is really in 
great danger from prolongation of the spasm, tracheotomy may 
be justifiable. Children who have laryngismus are generally 
anaemic ; requiring iron and salt baths, etc., to invigorate their 
constitutions. 

Ceoup. 

Croup is an acute cynanche or angina, whose signs are, a 
hoarse cough, difficult and audible respiration, and aphonia ; 
the seat of this disorder being the upper portion of the air 
passages. Its place in nosology has been empirically or con- 
ventionally (rather than systematically) established. 

For brevity's sake, the following propositions may be 
submitted : 

1. The pathological elements of croup are spasm; hyper- 
emia or congestion; inflammation, either ordinary or 
diphtheritic. 

The spasm affects the muscles whose action tends to close 
the rima glottidis ; but may involve also the muscular coat of 
the trachea itself. 

The hyperemia commences in the mucous membrane of the 
larynx or trachea, but often extends throughout the whole 
anterior cervical region. The inflammation may be located in 
a small portion of the same mucous membrane, or, it may 
extend downwards indefinitely into the bronchial tubes. 

2. We may mentally distinguish between cases in which the 
croupal dyspnoea results from simple spasm, from simple 



ceoup. 337 

tumefaction, or from inflammation without any spasmodic 
constriction of the glottis. In practice the pathognomonic 
cough and breathing rarely attend such an isolation of one o 
these conditions. A certain number of cases, however, occur, 
of purely spasmodic or nervous croup ; now and then substi- 
tuting more general convulsions; as when worms have been 
an exciting cause. A purely inflammatory case is equally 
rare. In fatal pseudo-membranous cases, autopsic examina- 
tion has shown that the amount of false membrane was by no 
means sufficient, alone, to have occluded the larynx or trachea; 
the result being due to the additional spasmodic contraction. 

3. The most frequent form of the disease, common night 
croup, is pathologically characterized by spasm of the glot- 
tidean apparatus, with congestion and tumefaction (transient 
in character), of the laryngotracheal mucous membrane. It 
is in these respects precisely analogous in nature to the asth- 
matic attack, whose seat is in the smaller bronchia?. There is 
no strongly-marked line of separation between this form and 
the catarrhal croup, or croupal catarrh, in which more or less 
active inflammation occurs, prolonging the existence of the 
symptoms. 

4. Viewing the hypersemic state as simply intermediate, we 
may classify cases of croup, as they ordinarily occur, clinically, 
as, 1, those in which spasm predominates; and 2, those in 
which inflammation is the dominant condition ; or into spas- 
modic and inflammatory cases. 

5. Pseudo-membranous, or "true croup," does not generic- 
ally differ from inflammatory croup; of which it is only a 
grade or termination, as any case of inflammatory or catarrhal 
croup may end in the exudation of coagulablc lymph within 
the air tubes. 

6. Whether this shall occur or not, in any given case, 
depends, 1, on the degree of the inflammation; 2, on the state 
of the blood of the patient; 3, on the treatment, 



338 croup. 

7. It cannot be predicated by experience, that either 
vigorous and plethoric, or feeble and ansemic children, are 
especially prone to the membranous form or termination of 
inflammatory croup. It may and does occur frequently in both. 

8. The ordinarily recognized signs for the diagnosis of 
inflammatory, from non-inflammatory croup, are sufficient as 
the persistent duration of the croupal cough and voice — the 
(generally) slow onset— the febrile symptoms — and the stridu- 
lous inspiration, as the dyspnoea increases. 

9. Inflammatory or true croup is, with the above inclusion 
(as always potentially membranous), not at all .necessarily 
fatal, although highly dangerous. The presence of the false 
membrane itself does not inevitably determine a fatal result. 

10. In no disease does more depend on early treatment, 
which is often prevented by the insidious approach of the 
attack, deluding the parents. The mortality of the disease 
may thus in part be accounted for. 

11. In the treatment of all forms of croup, relaxation and 
proper secretion are the two great indications. 

12. In the spasmodic cases, emetics and antispasmodics (as 
ipecacuanha, onion, assafoetida, lobelia, etc.,) will effect these 
objects, especially if aided by the warm bath or foot bath or 
both. 

13. In mild inflammatory cases, saline purging, gentle 
vomiting, and the use of demulcents, counter-irritation, 
pediluvia and inhalation of vapor will relieve. 

14. The most satisfactory emetic for employment in severe 
cases is a combination of ipecac and alum, the latter being used 
in half teaspoonful doses in urgent cases, until emesis is pro- 
duced. Nor should the practitioner hesitate to compel 
repeated vomiting at intervals, in desperate cases. 

15. Nitrate of potassium has experience and reason in its 
favor. Being a solvent of fibrin, it should tend to prevent 
the excessive coagulability or the exudation. According to 
late theories, ammonia might do the same thing ; but the 
clinical or therapeutic antecedents of ammonia point otherwise. 



croup. 339 

16. The great evil in membranous croup is the solidifying 
tendency of the exudation ; why should not, therefore, an 
abundant imbibition of fluids, even of water, do much toward 
the counteracting of this? Inhalation of steam, from hot water 
poured upon unslaked lime, is eulogized by recent writers. 
Glycerine and water aa in teaspoonful doses is recommended 
by others. 

17. No clear indication exists for the use of opium in the 
majority of cases of inflammatory or membranous croup ; 
although it may become useful, in cases which are protracted, 
or which are attended by a more than usual disposition to 
spasmodic symptoms. 

Blisters are decidedly useful ; but they should not be left on 
long in croup, a superficial vesication only being desired. 

The application of a strong solution of nitrate of silver to 
the fauces (and larynx, if possible) does good in many cases ; 
in the pre-exudative stage, as a medicament ; in the exudative 
as a mechanical operation aiding to dislodge the membrane. 

Iodide of potassium is too slow in its systemic action to be 
relied on ; and the same may be anticipated of the bromide, al- 
though nothing should forbid their fair trial. 

Tracheotomy or laryngotomy will, when performed early, 
succeed in a fair number of cases ; but in those very cases it is 
impossible to know that they (as well as those in which it 
fails) might not have recovered without it. Few practitioners, 
therefore, in this country, can demand the operation early ; 
and in the moribund state, the vascular congestion, from 
asphyxia about the throat, renders success extremely difficult, 
sometimes impossible. 

Dr. C. West, who has had but one recovery in sixteen 
cases, was obliged to admit its success, in some otherwise 
hopeless instances ; especially in France, where Trosseau and 
others operate earlier than in England or here. It is most 
generally fatal in children under three years of age. Where 
there is reason to suppose the membrane extends into the 



340 PLEURODYNIA. 

bronchial tubes, it is of course in vain. The danger of hem- 
orrhage is least if the operation is early. 

If performed, it should be deliberate, making a considerable 
opening of the trachea, and inserting a tube or canula of good 
size. Then the patient should be surrounded with a warm r 
moist atmosphere. The canula should be withdrawn in as few 
days as possible, upon the return of permeability to the 
larynx. The wound may then be treated with ordinary mild 
dressings to exclude the air and heal it up. 

Lately, the fact that lime will dissolve false membranes has 
been applied to the treatment of croup ; by making the patient 
breathe the steam from boiling water poured over unslaked 
lime. Although the lime is not volatile, some of its minute 
particles will be raised mechanically by agitation. Successful 
cases of its use are reported. 

Pleurodynia — Intercostal Eheumatism. 

Symptoms — Pain, generally rather dull, sometimes quite 
severe, of one or both sides, oftenest on the left. It is increased 
by deep breathing or coughing, moving the arms or trunk. 

Diagnosis. — From pleurisy, it is known by the absence of 
fever, and of all modifications of the sounds heard upon per- 
cussion and auscultation. 

Treatment. — A large mustard plaster over the part; 
friction with soap or volatile liniment; dry cups; a blister, or 
the hypodermic injection of morphia, if obstinate as well as> 
severe; relaxing nauseants and alkalies internally. 

Phthisis Pulmonalis — Consumption. 

Definition. — Caseous or tuberculous consumption of the 
lungs. 

Varieties. — Acute, chronic, and latent phthisis. 

Symptoms and Course. — Consumption may begin after a 
severe acute bronchitis or broncho-pneumonia; or, more 
gradually, with an apparently slight hacking cough; or with a 



PHTHISIS PULMONALIS. 341 

hemorrhage; or with dyspepsia and general debility; or with 
chronic laryngitis. Increasing, in most cases slowly, the 
pectoral and constitutional disorder becomes developed. We 
have then pains in the chest, frequent and severe cough, 
hemorrhage occasionally (in about two-thirds of the cases) and 
pallor, acceleration of the pulse and elevation of the tempera- 
ture, with the paroxysms of hectic fever, as chills followed by 
fever with bright flush of cheek but without headache; emacia- 
tion, arrest of menstruation in the female, night-sweats, col- 
liquative diarrhoea; finally, often, though not always, delirium; 
and death, mostly by exhaustion, but sometimes by suffoca- 
tion. The spirits of the patient are apt to be cheerful, even 
hopeful of life almost to the last. Appetite is variable, 
digestion usually not vigorous; but to this there are exceptions. 

The expectoration in phthisis is at first mucous or bloody; 
later, muco-purulent and bloody, or else nummular; as in 
roundish masses like coins, not floating perfectly in water; or, 
abundant and purulent. 

Stages. — 1. Incipient phthisis; 2. The stage of consolida- 
tion of the lung; 3. That of excavation or vomicae; 4. 
Advanced or confirmed consumption. 

Physical Signs. — Is there a pre-tubercular stage of 
phthisis? If so, it cannot be certainly pronounced upon. 
The earliest indications upon physical exploration are, a sink- 
ing in under the clavicle upon the left side, with prolonged 
expiratory sound. Not long after, the evidence of consolida- 
tion is, increased dullness over the apex of the lung upon 
percussion (not invariably but generally upon the left side) 
with blowing or bronchial respiration, or interrupted jerking 
respiratory murmur, and increased vocal resonance and vibra- 
tion. Dry crackling follows, with mucous or coarse crepitant 
rale. 

When softening of the tubercular deposits occurs, moist 
crackling and gurgling become very distinctive signs. The 
pressure of a vomica is shown by cavernous respiration and 
bronchophony or pectoriloquy. Percussion resonance over 



342 PHTHISIS PTJLMOSALIS. 

the cavity will be dull if its walls be thick, and amphoric if 
they are thin and tense; if thin and relaxed, the bruit depot 
fele, or cracked-pot sound. On percussion over a cavity when 
the patient's mouth is shut, the sound produced will be of a 
lower pitch than when the mouth is open. 

Pneumothorax and hydro-pneumothorax, i. e., dilatation of 
the pleural cavity and compression of the lung, by air, or air 
and liquid together with perforation of tne lung, are not 
uncommon results of tuberculization, although possible with- 
out it. Of pneumothorax, the percussion resonance is tym- 
panitic ; respiratory murmur lost. Hydro-pneumothorax may 
give tympanitic resonance above, with metallic tinkling on 
auscultation, and dullness below. 

Physical and Microscopical Peculiarities. — Tem- 
perature has of late been found to be a diagnostic aid in 
phthisis. It is asserted that there is a continued elevation of 
the heat of the body in all cases in which tubercle is being 
deposited; that this may occur four weeks before any local 
physical sign is discoverable; and that the rise in the heat of 
the body varies, during the progress of the case, with the 
greater or less activity of tuberculization. Exceptions occur, 
however, to the truth of this statement. 

When expectoration is copious, some necrologists aver that 
the diagnosis may be aided by its minute characters; arched 
and anastomosing fragments of pulmonary fibrous tissue, and 
tubercular corpuscles, being discerned. But it is not certain 
that the former are only thrown off in phthisis ; and the latter 
may be absent or obscure in character in an otherwise clear 
ca^e of consumption. Dr. Fenwick, of London, detects 
minute portions of lung-tissue by boiling the expectoration a 
few minutes with its bulk of solution of caustic soda (gr. xv 
in fBj of distilled water), and then adding cold water in a 
conical vessel. The sediment is then examined with the 
microscope. 

Terminations. — The cicatrization of vomica?, and the ces- 
sation of tubercular deposition, have, although exceptional, 



■ PHTHISIS PULMONALIS. 343 

been often found to occur; and so have the cornification and 
calcification of unsoftened tubercle. Recovery from phthisis 
may in such cases be expected to take place, as the arrest of 
the local disease only attends the presence of a favorable con- 
stitutional state. 

Death from consumption may come by asthenia or by 
apnoea. The first is most common. Suffocation or apncea 
may follow, 1, from hemorrhage; 2, rupture of a large vomica; 
3, pulmonary oedema or hydrothorax; 4, excessive secretion 
or bronchorrhcea, beyond the power of expectoration. 

Prognosis. — Phthisis is certainly one of the most destruc- 
tive of diseases. In no case can recovery be anticipated; but 
it does occur, as every physician must have witnessed. I 
have seen many of such recoveries; generally from the 
incipient stage, but even where vomica, emaciation, and 
night-sweats had occurred. Dr. A. Flint has recorded the 
history of sixty-two cases of restoration from consumption. I 
have witnessed as many cases of recovery. 

Under improved hygiene and medical treatment, the 
mortality from phthisis appears to be declining. 

The duration of phthisis varies greatly, being least, as a 
general rule, in the youngest subjects. Eighteen months to 
two years is the most frequent period. But in some instances 
life is prolonged under it for twenty, thirty, or even forty 
years. 

Acute phthisis, or galloping consumption, may end life in 
from six weeks to three months. This sometimes follows 
pneumonia. Its symptoms differ from those of ordinary con- 
sumption chiefly in their rate of progress. Softening of 
tubercle and the formation of cavities do not always occur to 
any extent, apnoea being caused by extensive diffusion or 
infiltration of the caseous or tuberculous deposit through the 
lungs. 

Causation. — Hereditary taint of constitution is general; 
independent origination of phthisis the exception. From 18 
to 35 years is the time of life most subject to it; but it is now 



344 PHTHISIS PULMONALIS. 

and then met with even in children, and frequently in the 
aged. Statistics in Europe and this country show some pro- 
portion between the mortality from consumption and nearness 
to the sea level; the lowest lands having the greatest total 
amount of it. High, dry, and equable climates and situations, 
even though cold, are most exempt from it. It is not a 
disease of the Arctic regions, and there is more of it in special 
areas of country. 

Individually, and in families, all causes that depress vitality 
promote it ; but most of all impure atmosphere and dampness of 
locality. Sedentary employments and exhausting excesses, 
with foul air, make large cities most of all productive of it. 
In constitutions having the proclivity towards it, tuberculiza- 
tion may be brought on by any reducing disease, especially 
such as involves the breathing organs: as measles, bronchitis, 
pneumonia, etc. 

Pathology. — It has, until recently, been the accepted 
doctrine that true phthisis was always a tubercular disease, 
whatever inflammatory and hemorrhagic symptoms occur in it 
being results of the deposition and changes of tubercles, either 
yellow or gray, in the lungs or elsewhere. Within a few 
years, however, a different view has met with much favor in 
the profession, under the teaching of Yirchow, Oppolzer, 
Niemeyer, and others. According to these authors, catarrhal 
or caseous pneumonia may be, or may become, when prolonged, 
phthisis pulmonalis, without any tubercular deposit. Second- 
ary deposition of tubercle may occur ; it is sometimes asserted 
(Buhl) that true tubercle is always secondary, depending on 
the absorption (resorption) of the caseous product of inflam- 
mation. Under the class of new growths, rare cases of 
destruction of lung are due to the breaking down with syph- 
ilitic gummata. Many pathologists now deny the tubercular 
nature of the yellow infiltration, insisting that only the miliary 
transparent and opaque granular matter are really tubercles. 
This subject is now undergoing special investigation. The 
production of tubercle in animals by inoculation is asserted by 



PHTHISIS PULMONALIS. 345 

authors. Tuberculosis of the lungs has, in some experiments, 
followed inoculation with pus, and other morbid products, as 
well as with tubercle, showing that it is not precisely a 
specific pathogenetic process. 

Anatomical Characters, — Earely the post-mortem 
merely shows the remains of an acute croupus pneumonia, 
which has ended in the destruction of the lung-tissue, usually 
much more. 

Treatment. — By general consent, hygienic management 
stands first in importance, while medicine is secondary in the 
treatment of pulmonary consumption; the latter* is indispensa- 
ble of course. Medication must meet indications as they 
occur. 

The objects to be kept in view in the treatment of phthisis 
are three: 1st, prevention and arrest; 2d, cure ; or, failing 
these, 3d, palliation of symptoms, and prolongation of life. 
Every case requires thoughtful consideration, and it must not 
be imagined that this is a disease capable of being controlled 
by any one remedy or class of remedies. An essential part of 
the treatment is the maintenance and promotion of a state of 
general good health and constitutional vigor as possible. 

1. General Hygienic and Dietectic Treatment. — This is of the 
utmost importance, both for prevention and cure, and without 
all other measures are unavailing. The chief are, a healthy 
residence, on a dry soil, in a suitable climate, elevated, but 
well protected from cold winds, with pleasant scenery and 
sufficient vegetation ; free ventilation, especially the sleeping 
apartments ; fresh air and exercise, as the powers of the system 
will permit ; the avoidance of crowded places at night, and of 
all causes which are likely to excite pulmonary affections ; 
the use of warm clothing, with flannel next the skin; the 
employment of baths, as they can be borne, with friction 
afterwards ; the administration of as nutritious a diet as can 
be assimilated, which should contain a good proportion of 
fatty elements; and the avoidance of all injurious habits, such 
as intemperance, excessive venery, &c. It is requisite to 



346 PHTHISIS PULMOXAL1S. 

inquire into the occupation, and to change this, should it 
entail long, daily confinement in a close room, with deficient 
exercise, or exposure to the exciting causes of lung diseases. 
The patient should be releived from severe mental labor or 
anxiety. The amount and character of the exercise must vary 
in different cases, such as aids in the expansion of the chest, 
especially in young patients, though kept within proper limits. 
Walking and riding are useful, and if these cannot be endured 
passive exercise must be enjoined, the patient being driven 
out daily when weather permits, so that a proper supply of 
fresh air may be obtained. Overfatigue must be avoided. 
Certain acts which call into exercise the muscles of respiration 
are useful, if duly regulated, such as deep inspirations, reading 
aloud, or moderate singing. Anything that interferes with 
the freedom of the respiratory movements, as the pressure of 
tight stays, or a bent position, ought to be forbidden. Milk 
and cream are valuable articles of diet ; also concentrated 
and digestible food. 

2. Where there is fear of phthisis setting in, attention 
should be paid to the least sign of pulmonary disorder. Tf 
acute, and of an inflammatory nature, the measures already 
mentioned when treating of the various inflammations must 
be employed. Acute exacerbations should receive attention ; 
it is very important to avoid lowering measures, and to pre- 
serve the strength. Everything which produces irritation of 
the lungs must be strictly avoided. 

3. Look to the state of the digestive organs. Unless digestion 
is carried on properly, all other measures are unavailing ; reg- 
ularity of meals and. other matters, upon which healthy 
digestion depends, should receive due consideration. If any 
form of dyspepsia is present, the appropriate remedies must be 
administered. Should there be evidences of gastric irritation, 
a combination of bismuth with an alkaline carbonate and 
hydrocyanic acid is beneficial. In the early period the bowels 
are often confined; some mild aperient must be given, so that 
they may be daily opened. 



PHTHISIS PULMONALIS. 347 

4. Various tonics and other medicines, which improve the 
state of the health generally, and of the blood, are very 
serviceable in phthisis. Of these the principal are the diluted 
mineral acids — nitric, hydrochloric, sulphuric, or phosphoric ; 
quinine ; different preparations of iron, especially if there is 
ansemia ; salicine ; strychnia ; and vegetable bitter infusions or 
tinctures, such as those of gentian, calumba, chiretta, quassia, 
cascarilla, etc. These and others may be given in various 
combinations so as to render them palatable. 

5. Among the special therapeutic agents recommended for 
phthisis cod-liver oil holds a good position. Experience has 
testified to its good effects in this disease. Only a small dose 
should be given at first, not too often repeated. A teaspoon- 
ful once or twice a day is sufficient at first, the dose being in- 
creased by degrees to a tablespoonful three times daily ; seldom 
desirable to exceed this quantity. Most patients take the oil 
best immediately or soon after meals ; lying down for a short 
time after taking it will prevent any ill effects. Some can 
take it best when going to bed at night. Use some vehicle 
for administering the oil, but the quantity of this should not 
be large. It may be given with the medicine, if this is of a 
bitter or acid nature or with steel wine. Milk, orange wine, 
stout, or a little cold brandy and water, are among the most 
useful vehicles. "When the oil causes sickness, it is well borne 
with lime-water and milk in equal parts, some of which may 
also be drunk after it. Small doses of strychnine have been 
found very useful in preventing the nauseating effects of the 
oil. It is important to see to the quality of the oil at first, 
otherwise a patient may get an antipathy to it. A good pale 
oil seems to answer best generally. Regularity and persever- 
ance in the use of the remedy are essential in order to realize 
the effects it is capable of producing. During its administra- 
tion the diet must be carefully attended to, and should not be 
of too rich a character. If it appears to disagree with the 
digestive organs it may be temporarily omitted during the 
warmer months. Some recommend cod-liver oil by inunction 



348 PHTHISIS PULMONALIS. 

or enema ; though necessary under some circumstances, these 
modes of administration are objectionable as a rule. Inunc- 
tion is often good in children. Special preparations have 
been made, as the "etherized oil," or a combination with 
quinine, hypophosphite of lime, etc. 

Substances are advocated as substitutes for cod-liver oil, but 
are less efficacious. Among these are olive, skate, shark or 
dugong oils, cocoanut oil, dog's fat, glycerine, and cream. 
The last two certainly produce good results in many cases. 

Pancreatic emulsion, introduced by Dr. Dobell, who also 
gives it with cod-liver oil; hypophosphites of lime, soda, iron 
etc.; phosphate of lime ; extract of malt ; maltin ; iodide of 
potassium ; sulphurous acid and sulphites ; arsenic ; koumiss, 
etc. These have been variously reported upon by different 
observers ; most of them are useful in certain cases, but can 
scarcely be considered specific remedies. 

6. Local Treatment. — Applications to the chest are useful 
in most cases, for the relief of symptoms, the subdual of in- 
flammatory processes; possibly, they may have an immediate 
effect on some forms of phthisis. The most useful are small 
or flying blisters ; applications of iodine, and liniments, tur- 
pentine, or acetic acid. In acute exacerbations, fomentations 
and poultices are required. 

7. Treatment of Symptoms and Complications. — Various 
symptoms call for attention during the course of a case of 
phthisis. Pyrexia must be subdued, if it is inclined to be 
high. Quinine in full doses, with digitalis may be given. 
Debility and wasting must be counteracted by the general 
treatment and by subduing the fever. When there is much 
exhaustion, considerable quantities of stimulants are required. 
Night sioeats are controlled by a pill at night, containing 2 or 
3 grains of oxide of zinc, or by a full dose of quinine, or gallic 
acid, or the administration a few days of a mixture of quinine, 
alum, and dilute sulphuric acid. Sponging the upper part of 
the body with vinegar and water or bay rum is useful. Pains 
about the chest may be relieved by the local applications men- 



PHTHISIS PULMONALIS. 349 

tioned, or by wearing some anodyne or warm plaster; cases 
with pain in the side, either muscular or pleuritic, may be 
relieved by strapping the side properly. Cough is often a 
troublesome symptom. It is not desirable to stop it; this must 
be influenced by the amount of expectoration;"' the discharge is 
to be encouraged, or its amount diminished by proper remedies. 
In most cases it should be relieved. The state of the throat and 
larynx may cause the cough. Local applications of tannin, 
chlorate of potash, or astringent gargles or lozenges, are 
beneficial. If the cough is irritable, various anodynes are 
valuable, as codeia, hydrate of chloral, bromide of ammonium, 
conium, belladonna, chlorodyne, etc., some of which may be 
combined. These may be given in the form of lozenges, 
syrups, etc.; give all cough-mixtures in small doses. Ano- 
dyne and other inhalations are serviceable, but not for any 
curative effect in phthisis. They are particularly useful if the 
larynx is affected. If the expectoration is fetid, disinfectant 
inhalations are beneficial. Dyspnoea and haemoptysis must be 
treated according to the ordinary principles. Vomiting is 
sometimes a very distressing symptom; if the ordinary reme- 
dies fail, small doses of strychnia often give satisfactory 
results. Diarrhoea, if due to ulceration of the bowels, is fre- 
quently very difficult to check. Powders containing 10 
grains of carbonate of bismuth, with 5 grains of Dover's 
powder, commonly stop it, but enemata of starch and lauda- 
num are most relied upon. Other complications must be 
attended to as they arise. 

8. Change of Climate and Sea-voyages. — This is an import- 
ant subject in the treatment of phthisis only the main 
principles can be indicated. As to climate the chief points 
are — that there is neither extreme of temperature; the air is 
pure, not too moist; the soil healthy; no likelihood of sudden 
changes, exposure to cold winds, or continued unfavorable 
weather. Choose a place where there is bright sunshine, 
attractive scenery, and pleasant company. One most import- 
ant object in selecting a climate is — that the patient may be 



350 CANCER OF THE LUNGS. 

out in the open air much. The salutary influence of high 
altitudes upon phthisis has been well established; patients 
should reside in warm and sheltered places during the colder 
months, and go to a high and dry region during the warm 
season. The exact qualities of the climate which are suitable 
for any individual case will depend upon its mode of origin, 
and the condition of the bronchial mucous membrane, as to its 
degree of irritability. Cases of constitutional origin are 
benefited by a sojourn in lofty regions. The seaside places 
suitable for phthisical invalids are the Isle of Wight, Madeira, 
West Indies, and the Azores, where both temperature and 
moisture are considerable. Among inland regions, Pau, Pisa, 
Upper Egypt, Syria, Australia, certain parts of South America, 
and California; or, if elevated districts are desired, the Alps, 
Andes, Himalayas, or American mountain ranges afford the 
requisite conditions. 

Long voyages, to Australia, or up the Mediterranean, are 
useful in cases, but should not be recommended if the disease 
is far advanced. 

A large number of patients are unable to avail themselves 
of the benefits of a suitable climate. Various hospitals 
established in seaside places afford these advantages more 
widely than formerly. If, during the winter months, patients 
are unable to get to a proper climate, they should keep 
indoors as much as possible in bad weather, avoid every cause 
of cold, and wear a respirator. Men should allow the beard 
and mustache to grow. 

CANCER OF THE LUNGS. 

Etiology. — This disease is rare; is most common from 40 
to 60 years of age, and more males are affected than females. 
It is supposed to be infectious, or inherited. It is generally 
secondary to cancer of the bones or testicles; may result from 
direct extention, or be primary in its origin. It generally 
extends, to involve neighboring parts, but rarely followed by 
econdary cancerous formations in other internal organs. 



CANCER OF THE LUNGS. 351 

Anatomical Characters. — Encephaloid is the variety of 
cancer usually in the lungs, and is often extremely soft, pulpy, 
and vascular. Other forms are occasionally seen alone or in 
combination, and deposit of black pigment, constituting 
melanotic cancer. 

Secondary cancer is generally in the nodular form, and 
affects both lungs; the nodules vary in size, and when at the 
surface tend to be depressed; by their union a lung may be 
involved throughout. Primary cancer involves only one 
lung, the right, and is infiltrated. After a time the cancerous 
matter undergoes fatty degeneration and softening, cavities 
being produced ; extravasations of blood are common. The 
vessels and bronchi are involved in the disease or obliterated 
by pressure. The unaffected part of the lung-texture may be 
normal, or various morbid changes are set up. A cancerous 
lung feels heavy. Extensive pleuritic adhesions usually 
occur. 

Symptoms. — Secondary cancer comes on insidiously, with- 
out subjective symptoms. In primary cancer, there is pain in 
the chest, may be severe, lancinating, with tenderness. Cough, 
with a peculiar expectoration, in the form of a substance 
resembling currant jelly, or cancer elements. Hcemoptysis is 
common. Dyspnoea is severe if there are projecting nodules, 
pressing on the nerves, or if the cancer is associated with a 
mediastinal tumor, when there are other signs of pressure on 
neighboring structures. 

The general symptoms are not as severe as might be 
expected. The cancerous cachexia may or may not be evident; 
emaciation, fever, night-sweats, with failure of strength, more 
or less, may be comparatively slight, in the secondary form. 
Wasting is rapid in its progress when once established. 

Physical Signs. — These vary according to the form, seat, 
and cancerous accumulation, and whether it is accompanied 
with a mediastinal tumor. Scattered nodules, the percussion 
and respiratory sounds may be altered. If a lung is exten- 
sively involved with nodular cancer, converted into a mass of 



352 RARE FORMATIONS IN THE LUNGS. 

encephaloid, the signs are: enlargement of the side, with 
widened and flattened spaces, the surface smooth without sense 
of fluctuation ; deficiency or absence of movement ; weakened 
vocal fremitus ; dullness, unaltered by position with sense of 
resistance ; breath-sounds weak or absent over a variable area ; 
vocal resonance deficient ; displacement of heart or diaphragm; 
the cardiac sounds to an unusual degree. In the infiltrated 
form, the lung is contracted; physical examination shows: 
retraction of the side, depression of spaces ; deficient move- 
ment, but the spaces still act ; vocal fremitus, increased, 
lessened, or absent, according to the amount of consolidation; 
hard, wooden, high-pitched or tubular percussion, which may 
extend across the middle line-, bronchial, blowing, or feeble 
respiratory sounds ; vocal resonance intensified ; displacement 
of the heart, with intensification of the sounds, and drawing 
up of the diaphragm. Ultimately there may be signs of 
cavities. In the non-cancerous parts, signs of hypertrophy, 
bronchitis and emphysema, are present. 

Prognosis is necessarily fatal, death occurring either from 
local or general causes. 

Treatment can only be palliative, and the usual remedies 
must be employed for symptoms as they present themselves. 

Bare Formations in the Lungs. 

It will necessary to enumerate these to indicate their 
possible occurrence. Those that require recognition include 
hydatids ; albuminoid degeneration ; sarcomatous enchondroma- 
tous, osteoid, or myeloid tumors, and hematoma. 

Haemoptysis — Pulmonary Hemorrhage. 

Haemoptysis, or " spitting of blood," signifies the discharge 
of blood through the mouth, from any part of the air-passages 
below the upper opening of the larynx. It may occur with- 
out warning, or preceded by premonitory symptoms, as weight, 



HEMOPTYSIS — PULMONARY HEMORRHAGE. 353 

fullness about the chest, dyspnoea, a sense of heat, tickling in 
the throat, or a saltish taste. Usually the blood is brought 
up by coughing, but it may arise in gulps without effort, or a 
sudden gush, when it may also escape through the nose; 
vomiting may occur. Quantity varies from a few streaks in 
the sputa to an amount sufficient to cause death. 

The blood is florid and frothy, occasionally dark, non- 
aerated, when abundant and suddenly discharged. Clots may 
be observed, but the greater portion is liquid. There is no 
change in the blood. The duration of haemoptysis varies; 
after the urgent symptoms have subsided, the sputa are tinged 
some time. Recurrence happens, in some cases periodical. 
If from the lungs in quantity, moist rales are heard over part 
of the chest. 

The effects on the system depend on the amount of blood 
lost, and the rapidity and duration of its discharge. Death does 
not often result immediately, but may occur from the loss of 
blood, or its causing suffocation. Frequently some febrile 
excitement is associated with haemoptysis, the pulse full, 
bounding, but soft. Should blood remain in the lungs, it may 
set up inflammation, and thus originate phthisis. 

Etiology. — 1. In some cases there is no obvious local 
disease. In this group may be included haemoptysis from 
going up a height, severe straining, coughing, blowing wind 
instruments, etc., which is apt to occur in those whose tissues 
are weak; vicarious haemoptysis; that due to the inhalation of 
irritating substances, or to injury; and that dependent upon 
an unhealthy state of the blood, as scurvy or purpura. 2. 
Diseases of the larynx, trachea or bronchi, as congestion, inflam- 
mation, ulceration, morbid growths, cancer. 3. Diseases of the 
lungs, as congestion, acute or chronic pneumonia, abscess, 
gangrene, hydatids, phthisis, cancer. 4. Mediastinal tumors, 
tubercular and cancerous glands, opening into the air-passages. 
-5. Cardiac diseases, as mitral disease, hypertrophy of the 
right ventricle, or a weak dilated left ventricle. 6. Disease 

26* 



354 HAEMOPTYSIS — PULMONARY HEMORRHAGE. 

of the pulmonary vessels. 7. Aneurism opening into the air- 
passages. 8. Blood sometimes gets into the windpipe from 
the throat or nose, and is expectorated. 

Haemoptysis generally comes from the capillaries; a branch 
of the pulmonary artery may give way, or is perforated by 
erosion. In phthisis minute aneurisms have been found upon 
the branches of this vessel, which have ruptured, and thus 
caused large hemorrhages. 

Diagnosis. — Haemoptysis may be simulated by bleeding 
from the mouth or throat, or by epistaxis. The quantity and 
characters; the mode of ejection; and, thorough examination 
of the nose, mouth, fauces, and chest, will indicate the 
source of the bleeding. The part of the organs from which 
the blood escapes is ascertained by physical examination, and 
the local symptoms. Erosion of a branch of the pulmonary 
artery is characterized by coughing up of dark blood. 

Treatment. — Haemoptysis must be treated on the princi- 
ples of hemorrhages in general, varying according to its 
cause. Keep the patient at rest in a cool room, a recumbent 
posture, with the head rather high; subdue cough; give ice to 
suck freely; and administer astringents with vascular seda- 
tives. Gallic acid in full doses with opium every two or 
three hours, dilute sulphuric acid and alum, turpentine, and 
ergot of rye. Ipecacuanha given to simply nauseate is often 
sufficient alone. The subcutaneous injection of ergotine is 
advocated. Digitalis is valuable, if the heart is acting 
excitedly. Saline aperients are useful if there is plethora. 
The application of ice to the chest is often beneficial; it 
must be done carefully, the ice being removed by degrees. 
Dry cupping over the chest is serviceable in some cases. 
Hot foot-baths, or a Junod's boot, or apply ligatures 
around the limbs. In all cases of haemoptysis of any 
moment, it is important to keep the patient under observa- 
tion until all irritation has subsided. Everything likely 
to bring on an attack must be avoided, while the; 



DISEASES OF THE CIRCULATORY ORGANS. 355 

condition of the blood is improved by proper diet and the 
administration of tincture of steel, etc. 



CHAPTEE IX. 

DISEASES OF THE CIRCULATORY ORGANS. 

The evidences of disease in the central organ for the circula- 
tion of the blood are not confined to this part but must be 
apparent throughout the system. Grave organic heart disease 
may exist without there being any evident symptoms to indi- 
cate it; and serious disturbance may exist about the heart, 
which is entirely functional. Other diseases are associated 
with cardiac affections, especially renal and pulmonary, which 
modify the symptoms much. 

Angina Pectoris — Suffocative Breast-pang. 

This is the only affection belonging to the subjective sensa- 
tions about the heart, which requires special notice. It is 
characterized by extremely painful sensations, with a sense of 
impending suffocation. 

Etiology. — Angina pectoris is a nervous affection associated 
with the cardiac plexus, accompanied with spasm or paralysis 
of the muscular tissue of the heart. It supervenes upon some 
organic disease of the heart or pericardium, not invariably; it 
is not confined to any particular morbid condition, most com- 
mon in extensive atheroma or calcification of the coronary 
arteries; fatty degeneration of the heart; and flabby dilatation. 
The exciting cause may be centric, as emotion; reflex, as from 
dyspepsia, cold, straining; or, some intrinsic disturbance of the 
cardiac ganglia. Certain distinct predisposing causes, as the 



356 ANGINA PECTORIS. 

male sex; advanced age, the complaint rare under 40 or 50; 
and a high social position. 

Symptoms. — An attack comes on with abrupt suddenness, 
but warnings of curious sensations or slight pain about the 
cardiac region. The first paroxysm occurs while the patient 
is walking up a hill, against the wind after a meal. 

The symptoms are intense pain in some part of the pre- 
cordial region, which may be excruciating. It may be shoot- 
ing, plunging, tearing, aching, gnawing, sickening, burning, 
often indescribable. A sense of oppression or constriction is 
felt across the chest, as if forcibly compressed and could not 
expand ; a sense of suffocation and inability to breathe, though 
this act is not interfered with, and there is no indication of 
cyanosis. If a deep breath can be taken and held, this may 
relieve the pain. Usually no tenderness, but relief from press- 
ure ; occasionally tenderness over the sternum and adjoining 
spaces. Painful sensations shoot from the heart, as down the 
left arm, even to the fingers ; sometimes the right, up the left 
side of the neck, backwards, or round the side. 

There is grave disturbance of the system. The face pale 
covered with cold sweat, and the expression is intense anxiety, 
alarm, and dread of impending death. The pulse feeble, 
fluttering or irregular if the attack is prolonged. Much de- 
pends on the condition of the heart in angina ; this is also true 
of the physical signs. Occasionally vomiting and eructations 
accompany the attack. The patient is quite conscious at first ; 
in prolonged or fatal cases may fall into a state of syncope, 
and spasmodic movements or general convulsions. 

Usually an attack consists of several brief paroxysms, with 
intermissions; there may be only one; the morbid sensations 
generally cease suddenly, this being attended with relief, a 
feeling of exhaustion afterwards, which may last some time. 
Rarely does the first attack prove fatal ; it may, suddenly or 
gradually. Some cases of sudden death are due to angina. 
A marked character of the complaint is its tendency to recur 
from slight causes. 



ANGINA PECTORIS. 357 

A form of angina pectoris is described, not attended with 
pain — Angina sine dolor e ; also an affection named pseudo 
angina pectoris, common among young persons, and attended' 
with sudden pain and unpleasant sensations about the heart, 
palpitation, disturbance of breathing, faintness and giddiness, 
pallor of the face, and feeble pulse. The condition of the 
patient may appear to be really serious, but very rarely does a 
fatal termination occur. This complaint occurs in ansemia, 
various nervous disorders, as hysteria, or blood-disease, as 
gout, etc. 

Prognosis. — True angina pectoris is very dangerous; that 
which simulates it is not; it is important to distinguish between 
them. The presence and nature of organic cardiac disease 
must necessarily influence the prognosis. 

Treatment. — 1. To prevent attacks, avoid exciting cause, 
and carry some remedy in the pocket to use immediately if 
there is the least indication of the approach of a paroxysm. 2. 
During an attack any obvious source of reflex disturbance, as 
indigestible food, must be removed. The internal remedies 
are sedatives, antispasmodics, and stimulants, full doses of 
hydrate of chloral, various ethers, chloroform, ammonia, musk, 
camphor, hot brandy and water, etc. Digitalis and bella- 
donna are recommended. Inhalations of chloroform, ether, or 
nitrite of amyl may be tried carefully in bad cases. The last 
has been well spoken of. Local applications of dry heat, ivith 
friction, sinapisms or friction with chloroform or belladonna 
liniment are useful. Gentle galvanism is recommended. In 
a gouty person the joints of the feet should be irritated. 3. 
During the intervals the treatment applies to cardiac affections 
in general, in the way of attending to the digestive organs, to 
the general and constitutional condition, and that of the blood 
and hygiene. Tepid 'or cold baths followed by friction, 
change of air and scene are beneficial. Also a belladonna 
plaster worn over the cardiac region. 

For pseudo-angina similar remedies are indicated during a 



358 I SYNCOPE. 

paroxysm, but they need not be so powerful. At other times 
the treatment must be directed to the state of the patient. 

Syncope. 

The phenomena are due to a failure of the heart action, 
speedily followed by disturbance of the nervous centres, due 
to anaemia, and this by failing pulmonary functions. 

Etiology. — The predisposing causes of syncope are early 
adult age; the female sex; a nervous temperament; and a 
state of weakness, with poor quality of the blood. Exciting 
causes. A condition allied to "shock," in which the three 
chief systems are simultaneously affected, the nervous centres 
are first. It is not easy to determine whether a case should 
be classed as one of syncope or shock. The causes are: 1. 
Want of blood in the heart; obstruction in the principal veins; 
or sudden removal of pressure from the great vessels, as when 
syncope follows paracentesis abdominis for ascites. 2. Inade- 
quate supply of blood to the cardiac walls, as obstruction of the 
coronary arteries; or a supply of impure blood, as in low fevers, 
or when syncope comes on in a hot and crowded room. 3. 
Partial or complete paralysis of the muscular tissue of the heart, 
from organic change, or nervous disturbance, centric, reflex, or 
intrinsic. Numerous causes act in this way, as fatty and other 
degenerations of the heart, flabby dilatation, or a weak state 
of this organ in chronic diseases, as cancer, phthisis, etc., 
sudden reflux of blood in aortic regurgitation; various poison- 
ous substances (aconite, tobacco, prussic acid, antimony, etc.); 
strong emotion and severe cerebral lesions; long continuance 
in a warm bath; reflex disturbance from bad smells, or un- 
pleasant sounds; pain of any kind; extensive burns; passage 
of a catheter ; a shock to the sympathetic, as from a blow in 
the epigastrium; drinking cold water when heated; taking 
indigestible food, or overeating after fasting, etc. Lightning 
sometimes produces death in -this way. 4. Continued spas- 
modic contraction of the heart, as in angina pectoris. 5. 



SYNCOPE. 359 

Mechanical pressure outside the heart, as great pericardial 
effusion. 

Anatomical Characters. — The state of the heart varies 
according to the cause. After great loss of blood, it is usually 
contracted and empty. When the walls are paralyzed, the 
cavities are dilated and contain blood, fluid or coagulated. 
The lungs are anaemic, and the nervous centres markedly so. 

Symptoms. — Syncope may come on suddenly, or cause 
instantaneous death. In many cases it is gradual, being 
premonitory symptoms before actual insensibility, as faintness, 
giddiness, trembling, with sinking in the epigastrium, nausea, 
and sometimes vomiting; pallor of the face, drawn features; 
chilliness and shivering, or a sense of heat, but cold, clammy 
perspirations; a rapid, small, and weak pulse, irregular and 
slow, the large arteries may throb; hurried, irregular breath- 
ing or gasping, sighing; restlessness; slight convulsive move- 
ments; mental confusion; disturbance of the senses of sight 
and hearing; dim vision; sensibility to light, and noises in the 
ears. When the syncopal state is complete, absolute insensi- 
bility, with dilatation of the pupils; deathlike pallor, cold and 
clammy sweats; a slow and extremely weak, irregular, or 
imperceptible pulse; infrequent, irregular respiration, which 
may ultimately cease altogether. Convulsive movements; the 
sphincters may relax, involuntary discharge of faeces and urine. 
Examination of the heart sIioavs feebleness or absence of impulse 
and sounds. 

This condition lasts a variable time, and ends in death or 
recovery. In the latter, uncomfortable sensations are experi- 
enced as the patient returns to consciousness, as palpitation, 
vomiting, or convulsive movements. 

Treatment. — Any reflex cause of syncope should be 
removed. The posture of the patient should be horizontal, wiih 
the head low. Fainting may be prevented by bending for- 
wards, hanging the head down between the knees. Clothes 
should be loosened, and plenty of fresh air admitted. Ammo- 
nia to the nostrils; dashing cold water in the face; or friction 



360 PALPITATION. 

with the hand or with stimulating liniments, along the limbs 
and over the heart, may restore vitality. The internal admin- 
istration of stimulants, as brandy, wine, ammonia, ether, 
musk, is useful, and if they cannot be swallowed, and there is 
danger, enemata should be employed. Attempt to confine the 
blood to the central organs by pressure on the arteries of the 
limbs, by the fingers or tourniquets, warmth being maintained 
by hot bottles and friction. Sinapisms, or turpentine stupes 
over the heart if necessary; in dangerous cases, regulated gal- 
vanism along the pneumogastric nerves, artificial respiration 
and transfusion, if there has been great loss of blood. 

Palpitation. 

Etiology. — A want of power; a laborious effort of the 
heart, being taxed beyond its powers. The individuals in 
whom it is most frequently seen are young adults and persons 
beyond middle age, females, nervous persons, and fat flabby 
people, who live highly, take but little exercise, and suffer 
habitually from dyspepsia. 

Exciting Causes. — 1. Acute or chronic organic disease of the 
heart or pericardium. This results from some obstruction to 
the circulation which the heart can not overcome. 2. Mechan- 
ical interference ivith the cardiac action is accompanied with 
palpitation, as tight lacing, distorted chest, displacement by 
pleuritic effusion, abdominal enlargements and flatulent dis- 
tension of the stomach. 3. Obstruction due to disease in the 
vessels ; if there is not adequate compensatory hypertrophy, 
palpitation is induced. Hence it occurs in atheroma, calcifica- 
tion, or hypertrophy of the arterial coats in Bright's disease. 
4. Chronic affections of the lungs, as bronchitis and emphy- 
sema, which interfere with the circulation, induce palpitation. 
It may depend upon the blood, either in quantity or quality, 
as plethora, anaemia, gout, renal disease, fevers, and admixture 
of materials taken into the system from without. There is a 
difficulty in driving on the blood, and the heart is disturbed 



PALPITATION. 361 

and supplied with impure blood. 6. Numerous causes act 
through the nervous system, directly from the centres, or reflex 
irritation, as continued cerebral excitement or mental labor ; 
emotion ; functional nervous disorders (hysteria, epilepsy, 
chorea, neuralgia) j the abuse of tea, alcohol, or tobacco ; reflex 
disturbance in the alimentary canal (as indigestible food), or 
in the genital organs. This nervous palpitation is due to 
spasmodic contraction of the arterioles, a difficulty in the 
passage of the blood, or innervation of the heart itself, its action 
less efficient. 

In some cases palpitation is always present, more or less 
increased by anything which throws extra effort upon the 
heart, as slight exertion. In other cases it is paroxysmal, 
brought on by some evident exciting cause, or independently 
of this. 

Irregularity is a form of cardiac disturbance alone or accom- 
panying palpitation, an indication of want of power. It may 
affect the rhythm, the force, or both. Rhythmical irregularity 
is due to a halting, hesitation, or partial arrest of the ventric- 
ular contraction, which may be brought on by disturbance of 
the balance of power between the vagus and cardiac ganglia, 
or between the opposition offered to the blood to be driven 
and the power to drive it. It is not necessarily associated 
with grave organic disease, dilatation, or low conditions of 
the system, as malignant fevers. The irregularity may be of 
a hesitating character ; sometimes it passes through regular 
cycles ; in other cases the cardiac action is confused. 

Intermittency is evidence of cardiac failure, a complete 
arrest in the ventricular contractions, until two or more 
auricular contractions occur before sufficient blood is sent 
into the ventricle to rouse it into activity. The conditions 
are fatty degeneration of the heart • aortic obstruction ; hyper- 
trophy and dilatation ; irritation of the vagus nerve, at its 
root from cerebral disease, or in its course from pressure of a 
tumor ; the advanced stages of severe fevers ; diseases of the 
lungs causing great obstruction, the left ventricle being dis- 



362 PALPITATION. 

turbed with the right; or mere nervous disturbance of the 
heart. It may be induced voluntarily, by holding the breath. 

Symptoms. — Palpitation, frequency and quickness of the 
heart's beats, when a severe paroxysm comes on. The action 
may be regular, irregular, or intermittent. There is also in- 
equality in force. Subjective sensations over the cardiac 
region, the patient conscious that the heart is acting, with a 
sense of rolling, jogging, falling back, jumping into the 
throat, and other indefinable feelings (precordial distress or 
anxiety). There may be pain, almost anginal, relieved in 
some cases by pressure. Daring severe paroxysms, faintness 
ending in syncope ; dyspnoea, with hurried breathing, and in- 
ability to a catch the breath ;" flushing of the face, headache, 
heat, giddiness, disturbed vision, and noises in the ears ; cold 
extremities. Sometimes anxiety and fear of death. The 
radial pulse corresponds to the heart's beats, though not 
always ; small and weak, though the heart is acting violently ; 
the large arteries throb quick and sharp. 

The duration and severity of palpitation vary much, the 
symptoms more severe where there is irregularity. It often 
terminates by profuse diuresis of light-colored urine, or a 
sense of exhaustion, calling for prolonged sleep. The palpita- 
tion due to drinking strong tea is sometimes of a distressing 
character. Occasionally it is constant in intensity, without 
organic disease ; some marked cases occur in young women. 

Physical signs due to mere palpitation are: 1. Impulse 
too extensive ; often strong, but not heaving ; may be irregular 
in rhythm and force, jogging, fluttering, etc. 2. Dullness, in- 
creased to the right in prolonged cases, from overdistension 
of the right cavities with blood. 3. Sounds louder than 
natural, with tendency to reduplication. 4. Occasionally a 
temporary systolic murmur at the base of the heart or left 
apex. 

Intermittent action of the heart, sometimes with distressing 
and horrible sensations, an intense dread of death. 



PALPITATION. 363 

Diagnosis. — Determine whether the disturbances of the 
heart's action are due to organic disease; this can only be 
done by physical examination, and by consideration of the 
circumstances of the case. The impulse of palpitation differs 
from that of hypertrophy, in not being heaving. 

Prognosis. — This will vary greatly, according to the cause, 
the presence and nature of any organic disease ; simple palpita- 
tion is not harmless; it may be a serious matter. Irregularity 
or intermittency is not a certain sign of organic disease; both 
conditions may be associated with mere functional disorder. 

Treatment. — 1. During a paroxysm of palpitation, the 
chief measures are, to get rid of every source of reflex irrita- 
tion ; to give antispasmodics, sedatives and stimulants, as 
brandy, ethers, ammonia, morphia, hydrocyanic acid, henbane, 
musk, tincture of lavender, galbanum, assafoetida, etc., as well 
as medicines which act upon the heart directly, as digitalis ; to 
apply dry heat or sinapsims over the precordial region and 
the extremities. 

2. During the intervals, or in chronic cases, look to the state 
of the heart ; digitalis improves its action ; avert every cause of 
-fits, by removing mechanical pressure, attending to diet, diges- 
tive organs, and habits; avoid excess in the use of alcohol, 
tobacco, or tea, overstudy, mental excitement, and veneeral 
excess ; treat constitutional diathesis as gout, and improve the 
nervous system and blood., with mineral tonics, acids, quinine, 
strychnine, or tincture of nux vomica, various preparations of 
iron, cold baths, with douches and frictions, proper exercise, 
change of air and scene into a pleasant climate. A mixture 
containing tincture of steel, nux vomica and digitalis, is benefi- 
cial. A belladonna plaster over the cardiac region. Similar 
treatment applies to the other forms of cardiac disturbance. 



364 ACUTE PERICARDITIS. 

ACUTE INFLAMMATION OF THE HEART AND 
PERICARDIUM. 

I. Acute Pericarditis. 

Causes. — Certain blood diseases, rheumatic fever and Bright' s 
disease, and occasionally in pysemia, typhoid, typhus, variola, 
scarlatina, puerperal fever, gout, scurvy, purpura, in cyanosis, 
or after the cure of chronic cutaneous diseases. 2. From 
injury, as a wound of the pericardium, or laceration by 
fractured ribs (traumatic). 3. From perforation, as asbcess 
opening into the pericardium (perforative) . Extension of in- 
flammation, or irritation by neighboring disease, as pleurisy, 
pneumonia, chronic cardiac disease, aneurism of the aorta, 
abscesses in the vicinity, carious ribs, tumors. 5. From the 
irritation of some new formation in the pericardium, as cancer 
or tubercle. 

Anatomical Characters. — They are similar to those in 
other serous inflammations, and run a similar course. The 
exudation is deposited on both surfaces, more on the visceral; 
rarely over the whole extent ; usually in patches ; may be 
confined to a small area about the great vessels. The thick- 
ness and mode of deposit are variable, the lymph being 
stratified, or little elevations, ridges, bands, masses, and other 
arrangements. Usually tolerably consistent, sometimes quite 
tough, adhering to the surface. In low conditions it may be 
soft and granular. The effusion is sero-fibrinous, containing 
flocculi; in exceptional cases it may have blood or pus mixed 
with it, rarely purulent. The quantity, from eight to twelve 
ounces, may range from an ounce to two or three pints. Gas 
is sometimes present, from decomposition. 

Definition. — Inflammation of the covering membrane of 
the heart. 

Varieties. — Simple or idiopathic, and rheumatic pericar- 
ditis. The latter is very much the more common. 

Symptoms. — Fever; pain (occasionally absent) at andradiat- 



ACUTE PERICARDITIS. 365 

ing from the heart; tenderness on pressure in the cardiac 
region; accelerated, irregular, or oppressed, rapid and feeble 
pulse; anxiety or delirium; nausea and vomiting in some 
cases; short hacking cough; towards the end, coldness and 
pallor or lividity, cedema of the face and extremities, loss of 
pulse. 

Stages. — 1. Acute inflammation; 2. Adhesion; 3. Effu- 
sion. 

Physical Signs. — Before adhesion or effusion, usually, 
exaggeration of the heart's impulse. Then, pericardial friction- 
sounds (to and fro), the vibration of which is sometimes felt 
by the hand. After effusion, dullness on percussion, with 
muffling of the heart's sounds to the ear on auscultation. The 
friction-sounds disappear during this period, sometimes to 
return as the effusion is absorbed. 

Diagnosis. — From endocarditis and from pleurisy it is 
sometimes not easy to distinguish pericarditis. The symptoms 
of the latter and those of endocarditis are the same; and the 
friction-sounds occur in both. The heart's impulse is more 
apt to be sustained in strength in endocarditis; and, in the 
latter, no dullness on percussion occurs, nor are the heart- 
sounds muffled at any stage; while valvular murmurs follow 
endo- and not pericarditis. 

Friction-sounds which are outside of the heart (pericardial) 
have a nearer character to the ear than endocardial sounds; 
they are more narrowly limited, not passing along the vessels; 
they do not keep exact time with the cardiac sounds, and may 
vary from day to day; and sometimes the vibration may be 
felt externally. 

Pleurisy causes friction sounds, and afterwards dullness on 
percussion. But the former sounds are more diffused, are 
generally single, not "to and fro" or double; and the dullness 
extends further over and around the side. Latent pericarditis 
may possibly, from some symptoms, be taken for inflamma- 
tion of the brain or of the stomach. Physical exploration 
should prevent such errors. 



366 ENDOCARDITIS. 

Prognosis. — There is great danger to life in pericarditis; 
and its course is sometimes terminated by death in a few days. 
In other cases resolution may take place promptly; but more 
often the heart is clogged for a considerable time (weeks or 
months) with effusion, or a more protracted interference occurs 
from adhesion of the pericardial surfaces. This latter is some- 
times shown by a dimpling, or sinking in, with each beat of 
the heart, of the intercostal spaces above and below 

TREATMENT.-^-In some cases, where fever is high and pain 
intense, heart sedatives, a brisk saline cathartic, as Epsom or 
Rochelle salts, or citrate of magnesium, should commence the 
medication. Fomentations over the chest, etc. 

Where the rheumatic diathesis is marked, alkalies will be 
indicated. Carbonate or bicarbonate of potassium, or bicar- 
bonate of sodium may be given, in scruple or half scruple 
doses, with as much of Rochelle salts, three or four times a 
day. A blister over the heart, as the fever lowers, will often 
have a good effect. If effusion occur, blistering may be 
repeated. A Dover's powder at night. 

For the stage of effusion, or "chronic pericarditis," the 
usual treatment consists of diuretics, as squills, juniper, sp. 
seth. nit. etc., varied and continued until absorption occurs. 
Tonics will often promote the same end. 

A rapidly depressing case of pericarditis, with cold, blue 
skin, and feeble, irregular pulse, will require, instead, a sup- 
porting or stimulating treatment from the first; with dry cups 
and blisters; and quinine, ammonia, and whisky, instead of 
sudorifics or laxatives. 

Myocarditis is inflammation of the muscular substance of 
the heart. It can hardly have other than a nominal existence. 

II. Endocarditis. 

Definition. — -Inflammation of the lining membrane of the 
heart. 

Symptoms and Physical Signs; Diagnosis. — These 



ENDOCARDITIS. 367 

have been sufficiently stated in the account just given of 
pericarditis, and need not be repeated. Like that disease, it 
is most often of rheumatic origin; but may occur in Bright' s 
disease or in pyaemia. 

Valvular derangement and its signs give great interest to 
endocarditis and its resulting changes. Mostly it is the left 
side of the heart that is chiefly affected. The simplest and 
most common sign of this is a blowing sound, heard on 
auscultation. But a bellows murmur is heard also in cases 
of anaemia, and a blowing sound occurs not rarely in fevers; 
or it may belong to an organic heart-affection of long standing. 
This last fact should be ascertained by the history of the 
patient, as well as by the aid of symptoms; but the old 
murmur is generally rougher and more fixed in its seat. It 
is possible, though rare, for endocardial inflammation to be 
located so far from the valves as to cause no blowing sound. 

Clots sometimes form in the heart in endocarditis (as well as 
in some other diseases attended by prostration), obstructing 
the circulation, even to a fatal extent. Although most clots 
are post-mortem in origin, there is no doubt that sometimes 
firm fibrinous masses do occlude the valves for some time 
before death. The symptoms produced are, blueness and 
coldness of the skin, indistinctness of the heart-sounds, 
feebleness and irregularity of the pulse, nausea and vomiting, 
anxiety of expression and fainting. 

Much more often, vegetations or fibrinous deposits of exuda- 
tion on the valves of the heart are carried in fragments 
therefrom by the blood into the arteries. Being arrested, as 
in a vessel of the brain, or a limb, etc., the condition of 
obstruction designated as embolism results ; which receives 
attention in another part of this book. Old valvular vegeta- 
tions, as well as the recent ones of endocarditis, may give rise 
to emboli ; which, also, arise from coagulation in a vein, or 
thrombosis. 

Endocarditis produces valvular derangement in the mitral 
valve most frequently in the young ; in the old (from this 



368 ACUTE MYOCARDITIS. 

cause as well as from degeneration), disease is rather more 
common in the aortic valve. The forms of disorder, indicated 
by murmurs, occur in the following order of frequency; 1st. 
Aortic obstructive ; 2. Mitral regurgitant ; 3. Aortic regur- 
gitant ; 4. Aortic obstructive and mitral regurgitant together. 

Enlargement of the heart, either with muscular thickening 
(hypertrophy) or with attenuation (dilatation) is a common 
consequence of endocarditis with valvular lesion. In every 
case the important question is, less the state of the particular 
valves, than the amount of interference with the functional 
action of the heart. In young persons, remarkable recoveries 
sometimes take place from very considerable lesion of the 
valves. In other instances adaptation of the heart itself, and 
of the general system, by degrees, is effected, so that quite 
good health, and even capacity for exercise, may be attained, 
while the physical signs of the local organic change remain. 
Sudden death is less common in heart-disease than is popularly 
supposed. Some persons having it have lived twenty or 
thirty years. Dr. Black has shown the great importance of 
breathing pure air to persons who have symptoms of heart- 
disease after middle life. 

Treatment. — Nothing can be done directly for endocar- 
ditis, and the treatment is mainly that of the disease in the 
course of which it occurs. In rheumatism alkalies should be 
given freely, so as to render the blood less irritable. As a 
rule stimulants are required in endocarditis, in some cases in 
large quantity, with abundant nutriment. Digitalis is indi- 
cated if the heart is failing. Should there be signs of 
obstruction from coagulation, it is recommended to give 
alkalies and carbonate of ammonia freely, with alcoholic and 
other stimulants. 

III. Acute Myocarditis. 

A brief consideration must suffice for inflammation of the 
heart-substance. It is frequently set up inthe layers contig- 



VALVULAK DISEASE. 369 

nous to an inflamed endocardium or pericardium. It may 
occur independently in a few instances, either as a diffuse 
inflammation or localized, the latter terminating in abscess. 
Pyaemia and septicaemia lead to myocarditis, and formation of 
abscesses. 

Myocarditis is attended with discoloration, softening, infil- 
tration with a sero-sanguineous fluid, exudation, sometimes 
pus, may collect in abscesses. May lead to the formation of 
cardiac aneurism or rupture of the heart. If recovery takes 
place, depressed scars may be left. 

The symptoms and signs are very obscure. It tends to make 
the cardiac action weak and irregular; when this is a promi- 
nent feature in the course of peri- or endocardatis, implication 
of the heart may be suspected. The general symptoms are 
pyrexia of an adynamic type, with signs of blood-poisoning 
and collapse. 

The only treatment affording any hope is free stimulation. 

Yalvulae Disease. 

The valves of the heart may be impaired either by inflam- 
mation or by degeneration (as calcareous deposit or "ossifica- 
tion"). The latter, degenerative valvular changes, occur 
gradually; and mostly late in life. Either form of valve- 
disease, or at least of valvular alteration, is generally perma- 
nent; the degenerative form almost invariably so. 

Changes may occur, by simple thickening, or by deposits of 
fibroid, fatty, or calcareous material; or by atrophy, contrac- 
tion, adhesion, or ulceration of the valves; or gouty deposits 
of urates and carbonates of sodium and calcium. The valve 
(mitral or aortic primarily, or tricuspid or pulmonary second- 
arily) may be thus rendered incapable either of perfect closure, 
or of full opening; in most instances at least, a permanently 
lialf-open state results. 

A considerable variety of pathological conditions may exist 

*27 



370 VALVULAR DISEASE. 

in organic disease of the heart; while the number of cases in 
which an exact and unequivocal diagnosis can be made is 
comparatively small. We must not confine' attention at all to 
the physical signs alone, but compare also with these the pulse,, 
the force of the heart, other general symptoms, and the entire 
history of the case. 

Certainty can hardly ever be obtained, unless it be (Stokes) 
in the diagnosis of one of the following three conditions : 

1. Uncomplicated disease of the mitral valve. Signs of 
this are — a permanent murmur, with the first sound, loudest 
towards the apex and left side, and not heard over the aorta; 
the second sound natural. The heart's action natural; the- 
impulse not excited, the pulse natural. 

2. Disease of the aortic valves, with permanent openness. 
With this, there is no murmur with the first sound; the second 
sound is replaced by a double murmur, loudest at the base of 
the heart, and heard along the aorta. In an advanced stage 
of this condition, the arteries give to the finger, or even to the 
eye, an impression of bounding pulsation; with a jerking, or 
abruptly ending pulse at the wrist. 

3. Disease of the aortic valve, without permanent openness. 
Here, the action of the heart is slow and feeble, generally 
regular, or only occasionally intermitting. A murmur is 
heard with the first sound, the second being healthy ; but a 
murmur may be heard with the second sound, in the aorta and 
carotids. 

It must be noticed that in anaemia, without heart-disease, a 
bellows murmur is often heard, extending into the arteries. 
Chiefly by the concurrent signs and symptoms this is 
distinguished from organic disease of the heart. Anaemic 
murmurs are more variable, and are not much increased by 
moderate exercise. 

When the aortic valvular orifice is greatly contracted, the 
pulse at the wrist may become very feeble, almost absent, 
while the heart's impulse is strong. 

Advanced mitral or aortic disease is accompanied usually by 



ENLARGEMENT OF THE HEART. 371 

derangement, sympathetic or obstruct] ye, of the lungs, liver, 
and other organs; with haemoptysis, anasarca, cyanosis, irreg- 
ularity of the pulse, syncope, etc. Pulsation of the jugular 
veins indicates mostly secondary disorder upon the right side 
of the heart, with regurgitation into the venae cava?. Pseudo- 
apoplectic syncope may occur in permanent patency of the 
mitral valve; or in fatty degeneration of the heart, with or 
without valvular disease. 

Enlargement of the Heart — Hypertrophy. 

Uncomplicated dilatation of the whole heart, or of either 
pair of corresponding cavities, or of any one cavity, is very 
uncommon. Complicated dilatation is frequent. It may 
depend — 1, on a debilitated state of the cardiac muscle; 2, on 
valvular disease; 3, on obstruction beginning in organs remote 
from the heart. 

The commonest form of dilatation makes part of a triple 
affection, in which the heart, lungs, and liver are together 
involved. All this may come, in the first place, from a 
cachexia, such as gout or scurvy, or from simple anaemia. 
Exacerbations in the disorder may occur; as, of pulmonary 
congestion, enlargement of the liver, cardiac asthma, bron- 
chitis, or dropsy. The prognosis cannot be very favorable in 
such a case; and only palliative, or recuperative, treatment 
avails, along with hygienic management, to economize the 
powers of nature. 

Dilatation of the heart is indicated, upon physical explora- 
tion, when, with extended impulse of the heart, we have 
dullness on percussion beyond the usual limits. If true hyper- 
trophy, or muscular thickening, be present, the impulse is 
very forcible as well as extended. The heart-sounds are apt 
to be clear, though not loud, in attenuated dilatation; rather 
loud, but dull toned, in enlargement with thickening of the 
walls. But these differences are hardly to be relied upon. 

Hypertrophy of the muscular tissue of the heart is most 



372 ATEOPHY OF THE HEART. 

often induced by valvular obstruction or regurgitation, com- 
pelling unusual and continued efforts to sustain the 
circulation. 

Sometimes, however, it is more truly idiopathic; following 
causes of overaction of a heart otherwise sound. Thus, 
violent exercise, self-abuse, coffee, alcohol, tobacco, etc., are, 
with good reason in predisposed cases, accused of produc- 
ing it. 

Treatment of simple hypertrophy; avoidance of exciting 
causes, of violent exercise, alcohol, and venery, is the main 
principle. 

Digitalis was formerly relied upon as a reducer of cardiac 
action. Lately the question has been opened widely,, whether 
it does at all tend directly to lower the heart's action; or 
whether it is not, instead, a tonic to the heart (probably 
through ganglionic influence), lessening rapidity of action 
only when that depends on debility. The time has hardly 
come to pronounce finally upon this question. Evidence has 
been given to encourage us to use digitalis unhesitatingly 
where abnormal rapidity of the heart's action exists in condi- 
tions of debility; and to expect more from veratrum viride as a 
sedative and palliative, in violent acceleration of the pulse, as 
in muscular hypertrophy, and in some forms of palpitation. 
Tincture of cactus is often preferred. Fulfill indications as 
demanded in various cases. 

Atrophy of the Heart. 

Etiology. — Atrophy of the heart may be met with under 
the following circumstances : 1. As a congenitul condition. 
2. In general wasting from old age, starvation, low fevers, 
phthisis, cancer, and other affections inducing marasmus. 3. 
From pressure upon the heart, by pericardial agglutinations 
or effusion, or excessive accumulation of fat. 4. Disease or 
obstruction of the coronary arteries, the heart being imper- 



FATTY DEGENERATION OF THE HEART. 373 

fectly nourished ; the atrophy is then accompanied with 
degenerative changes. 

Anatomical Characters. — Diminution in weight to 3i 
ozs., or less. The heart is small, its cavities contracted, of 
normal shape. An eccentric form is described in which there 
is dilatation as well as atrophy. The muscular tissue is want- 
ing in tone, and fatty degeneration is common. 

Symptoms. — Feebleness of the circulation is the symptom 
attributed to atrophy. When due to pressure on the heart, or 
interference with its supply of blood, severe symptoms are 
present, as palpitation, dyspnoea, venous congestion; these are 
not the immediate results of the atrophy. The physical signs 
are: 1. A feeble impulse, which may be raised. 2. Diminished 
area of dullness. 3. Weak or sometimes almost extinct sounds. 
4. Pulse small, feeble, but regular. 

Fatty Degeneration of the Heart. 

Definition. — Substitution of fatty substance for the mus- 
cular tissue of the heart, to such an extent as to interfere with 
its normal action. 

Symptoms and Course. — Always gradual in its progress, 
this in many instances fails to make itself known until a late 
period; sometimes till the moment of death. Feebleness, 
irregularity of the pulse and heart's impulse, exhaustion and 
dyspnoea upon exertion. The pulse is slow when at rest; 
sometimes only thirty, although the heart beats fifty or sixty. 
Attacks of syncopal apoplexy may occur; at first most like 
syncope, after repetition becoming more apoplectic. These 
are distinguished from true apoplexy by the feebleness of the 
pulse, coldness of the skin, sighing respiration, and slightness 
or absence of paralytic symptoms, notwithstanding several 
repetitions of the attack. They are worse by reduction of the 
system; may be relieved or warded off by timely stimulation; 
the recumbent posture is most favorable. The first attack 
may prove fatal. 

Physical Signs. — Fatty degeneration is often complicate 



374 MODES OF SUDDEN DEATH IN HEART DISEASE. 

by the presence of other structural changes 'of the heart. By 
itself, it is with difficulty diagnosticated. The heart's impulse 
is feeble and slow, often irregular, and the sounds weak. A 
bellows murmur is frequently heard with one or both sounds. 

Moebid Anatomy. — True fatty degeneration must be dis- 
tinguished from fatty accumulation about the heart, which 
may impede its action, but is much less dangerous. In true 
interstitial degeneration, the heart is, in part or throughout, 
Habby and pale or yellowish, though it may be more bulky 
than usual. Minutely examined, the muscular fibrils are 
found to have lost their transverse striae, and to have resolved 
themselves into streaks of oil-dots or opaque granules. 

Death, sometimes, results from rupture of the heart. In 
other instances that organ has, under some exertion or excite- 
ment, become exhausted and failed to act sufficiently to keep 
up the circulation. 

Prognosis. — Recovery is not to be expected; life may be 
prolonged to old age. Much depends upon circumstances of 
living, and care to avoid disturbing agencies. 

Causation. — In early life this affection is uncommon ; its 
most frequent cause is, then pericardial or endocardial in- 
flammation. Most cases are met with after fifty years of age. 
It then occurs as one of the local manifestations of waning 
vital energy; but it may be promoted by any or all exhaust- 
ing or depressing causes. No special or peculiar line of 
causation can be pointed out. 

Treatment. — This can be only conservative, not curative. 
Tonics, with generous diet, sea or mountain air, change of 
scene, and avoidance of anxiety and exertion, may do much to 
retard the degenerative process. Violent effort or emotional 
excitement may be suddenly fatal. Tranquil occupation only; 
all rapid exercise, and straining at stool, ought to be avoided. 

Modes of Sudden Death in Heart Disease. 

To briefly enumerate these: 1. Arrest of the heart's 
action from debility of the muscular walls; 2. Spasm of the 



THYRO-CARDIAC DISORDER. t 375 

Tentricles ; 3. Extreme obstruction, or regurgitation; 4. 
Rupture; 5. Heart clot. Indirectly, cerebral or pulmonary 
-apoplexy. 

ThyroCardiac Disorder. 

Synonym. — Ex-ophthalmic Goitre. Basedow's or Graves' 
Disease. 

Definition. — Enlargement of the thyroid gland in the 
neck with over-action of the heart and cervical vessels, and 
prominence of the eyeballs. 

Nature. — This uncommon disease is considered by Dr. 
Stokes to consist in a more or less permanent functional excite- 
ment of the heart, which may produce finally dilatation and 
hypertrophy, with dilatation also of the jugular veins, and an 
aneurismal condition of the thyroid gland. Although con- 
siderable disturbance and prostration of the system must 
attend such a state of things, yet it has been repeatedly 
recovered from. The cause of the affection has not been 
made out. 

Treatment. — Tranquil lization of the heart is the main 
indication. Veratrum viride, in doses not at all nauseating 
(two or three drops of the tincture every three or four hours), 
may be persevered in, while watching its effects. Other 
treatment must depend upon the general condition of each 
patient. Of course violent exercise and mental excitement 
must be avoided. 

General Diagnosis of Chronic Cardiac Diseases. 

The questions to be decided in making a diagnosis of the 
heart may be stated : 1 . If there is any real organic mischief, 
or merely functional disturbance, should^there be any symp- 
toms affecting this organ? 2. If the former, its nature, exact 
seat, and amount ? The main conditions are different valvular 
diseases, alteration in the size or capacity of the heart, changes 
in its walls, interference with its supply of blood, and peri- 



376 CHRONIC CARDIAC DISEASE. 

cardial effusion or adhesion. These are often presented in 
various combinations, and an endeavor should be made to 
determine the exact state of the structures in every particular 
mentioned. 3. If possible the pathological cause of any lesion 
present should be ascertained. The data on which this should 
be founded are: 1. The previous history of the patient, 
special inquiry as to acute rheumatism, and violent exertion ; 
any family predisposition to cardiac disease. 2. The age r 
sex, and general condition ; whether there are signs of degen- 
eration. 3. The symptoms present, if the circulation is 
disturbed in any way, and the effects produced. 4. The 
physical signs. Physical examination is the only positively 
reliable means of diagnosis, and daily experience enforces the 
importance of thoroughly investigating the state of the heart 
in any case which comes under observation for the first time ? 
and especially when examining for life insurance. The points 
are : Whether any change in shape or size over the cardiac 
region ; the characters of the impulse* in every particular ; the 
position, form, and extent of the cardiac dullness ; the charac- 
ters of the sounds compared over different parts ; if there is 
any pericardial or endocardial murmur. Examine carefully 
the arteries and veins, making use of the sphygmograph in 
connection with the former; observing whether there are 
evidences of degeneration in them. 

It is necessary to give attention to the following facts: 1. 
The heart may be displaced by conditions external to it, 
giving rise to abnormal physical signs, when it is not itself 
affected ; while signs of organic disease may be modified by 
the state of contiguous structures. 2. Murmurs may be 
present independently of organic disease, or merely from 
roughness of the endocardium, unattended with any danger. 
3. The bulging or dullness associated with pericardial effusion 
or cardiac enlargement may be simulated by excessive tem- 
porary distension of the right cavities of the heart; aneurism 
of the aorta ; tumor, abscess, or accumulation of fat in the 
mediastinum; localized pleuritic effusion; consolidation or 



'I 

GENERAL PROGNOSIS. 377 

V 

retraction of the anterior edges of the lungs, especially the 
left. 4. Positive organic disease may exist without there 
being any distinctive signs, particularly degeneration in its 
less advanced stages. 5. Severe symptoms may be complained 
of, and there may be marked objective disturbance of the 
cardiac action, amounting to irregularity or intermittency, 
from mere functional disorder. Much stress has been laid on 
certain points, whether local symptoms are due to organic 
mischief, viz., that mere functional disturbance is not in- 
creased by effort, is inconstant, and usually brought on by 
some obvious exciting cause. Avoid putting any very implicit 
reliance on these distinctions, except that grave disorder 
following slight exertion may indicate degeneration. 

General Prognosis. 

Any organic affection of the heart is serious ; numerous 
circumstances affect the prognosis, and every case has to be 
considered in several aspects before a satisfactory opinion can 
be given. Great care should be exercised against mistaking 
mere functional disorder for organic disease, and vice versa ; 
it is improper to found an opinion on mere subjective 
symptoms. 

The questions to be considered are : 1. Whether there is 
any danger of sudden death. 2. What is likely to arise in the 
progress of the case and dangers. 3. The probable duration. 
4. Is a cure possible ? 

1 . The prognosis depends on the nature, seat, and extent of 
the disease ; is more than one form present, founded on a 
satisfactory physical examination? Mere roughnesss of the 
endocardium, is attended with a murmur. The mischief 
may spread to the orifices and valves or their appendages. 
These are serious, but very different at the different orifices, 
and depend upon their precise condition. In estimating the 
probable evils, what way the various lesions influence the 
circulation, and the changes they are likely to produce in the 



378 GENERAL PROGNOSIS. 

heart : upon these points the prognosis will rest. As to sudden 
death, aortic regurgitation is the form of valvular disease in 
which it is frequent ; it has been stated to occur in mitral re- 
gurgitation. Obstructive disease on the left side is injurious 
by its " back- working/ 7 and its effects on the heart and circu- 
lation. Aortic obstruction lasts a long time without particular 
evils ; cases of mitral constriction also go on for a considerable 
period. Mitral disease is dangerous from its effect on the 
lungs. Tricuspid regurgitation is a serious affection of the 
orifices, on account of distressing symptoms by which it is 
followed, often speedily, by overloading the venous circulation; 
its course is tedious, leading a miserable existence. Pulmonary 
constriction acts in the same way. Extensive or double 
disease at an orifice increases the gravity. It is worse when 
two or more orifices are involved; an opening secondarily 
may give temporary relief, as of tricuspid regurgitation 
following mitral disease diminishes the severity of the pul- 
monary symptoms. 

Is valvular disease curable? I have met with cases in 
which marked mitral constrictive murmur has disappeared in 
young persons ; though restoration to normal condition is not 
possible, it is likely that inflammatory deposits, leading to 
both aortic and mitral obstruction, may be partly absorbed in 
time. 

Hypertrophy is a preservative or compensatory lesion, not of 
evil import. It is dangerous when excessive, as it may lead 
to rupture of vessels, diseased which it tends to produce 
through constant overdistension; when on the right side, it is 
further injurious in keeping^up a constant state of active con- 
gestion of the lungs. 

Dilatation is a dangerous condition, in proportion to degree, 
and excess over hypertrophy. Sudden death may occur in a 
weak, flabby, dilated heart, and augments the difficulties in 
the circulation, Contributing to dropsy and other serious 
symptoms. 

Degeneration of the heart's walls, fatty disease, is another 



GENERAL PROGNOSIS. 379 

grave lesion ; when this sets in the prognosis becomes worse 
in compensatory hypertrophy. Extensive fatty degeneration is 
the most frequent cause of sudden death. 

Pericardial agglutinations add to the evils of other lesions, 
and tend to produce changes in the heart ; this condition 
seems to have influence in bringing a fatal pneumonia. 

These affections are variously combined, and the prognosis 
has then to be gathered from a careful determination of the 
exact lesions present. 

2. Severe anginal attacks, great irregularity or intermit- 
tency of cardiac action, a tendency to syncope or apoplectiform 
or epileptiform seizures, increase the danger. When venous 
circulation becomes obstructed, and dropsy sets in, the dura- 
tion is not apt to be prolonged, yet patients often linger, and 
may improve under appropriate treatment. Acute pulmonary 
complications may arise and produce very severe symptoms, 
increasing the dropsy and the case appears approaching a ter- 
mination; on the subsidence of these, improvement may take 
place, and the patient again for some time may feel better. 

3. The cause of the disease may influence the prognosis, as 
regards improvement in valvular disease; it is only when this 
results from acute inflammation that any such hope can be 
entertained. If induced by chronic and degenerative changes, 
matters always tend to worse. Some regard a certain degree 
of hypertrophy, or even dilatation, as capable of being cured, 
if the cause can be removed. 

4. The state of other organs and structures, especially the 
lungs, kidneys, and arteries, should modify considerably the 
opinion in any given case, and hence their condition ought to 
be carefully investigated. If the vessels are diseased, the 
structure of the heart is very likely to undergo degeneration. 

5. General matters affecting prognosis are the age, the 
family history indicating a tendency to death from heart- 
disease; the social position, and habits of the patient. Only 
in young persons can curative changes be expected. Those 
who are circumstanced to live quietly, without anxiety or 



380 GENERAL TREATMENT. 

labor, and have a suitable diet, have a better chance of length 
of life than those not so fortunately situated. Laborious 
occupations are injurious. Continuance in evil habits, as 
intemperance or debauchery, will render the prognosis 
unfavorable. 

General Treatment. 

Seldom can hope be entertained of curing chronic cardiac 
affection; much may be done in prolonging life, averting 
further mischief in the heart, warding off unpleasant or dan- 
gerous symptoms, and relieving them when they arise. After 
an acute affection involving the heart, the patient should be 
kept under observation until the organ has resumed its 
normal condition, so far as is possible ; any chronic case ought 
to be kept constantly under medical supervision. Different 
forms of heart disease indicate particular modifications of 
management ; the main principles which apply to all varieties 
more or less, are : 

1. General hygienic management is of essential importance. 
A patient suffering from heart disease should give up laborious 
employment, if this originated and is increasing the mischief. 
Avoid sudden effort ; running or walking hurriedly, and strain- 
ing at stool. In some instances complete rest should be 
enforced for a time, which often produces a marked improve- 
ment. Many cases are benefited by being in the open air 
during some portion of the day, and carriage driving is often 
useful. Many patients can go about their usual avocations 
without any harm resulting, if these are of .a satisfactory 
character. The amount of exercise must be determined by 
the conditions present, the effects it produces ; in proportion 
to the degree of dilatation or degeneration present is the 
capacity for effort diminished. These lesions, if extensive, 
and aortic regurgitation, imperatively forbid any great exertion. 
Avoid all causes of mental disturbance. Anxiety or excite- 
ment about pecuniary matters, business, politics, excessive 
study, and all strong emotions must be shunned, and a proper 



GENERAL TREATMENT. 381 

amount of sleep should be habitually obtained. Warm 
clothiug, but no pressure or constriction about the chest or 
neck; cold sponging followed by frictions of the skin are use- 
ful, if well borne. All habits which depress the energy of the 
heart, as abuse of alcohol, tobacco, tea, late hours, or venereal 
excesses, etc., must be prohibited. Close inquiry may be 
necessary to detect mischievous habits. Change of air to a 
moderately warm and bracing climate does good. 

2. Attend to the diet in every particular, and to the state of 
the digestive organs. When there is degeneration of the heart, 
a nutritious diet containing protein elements, if these can 
be digested ; anything which gives rise to indigestion 
must be avoided. Milk and cream are useful in many 
cases. As to alcoholic stimulants, no rule can be laid down, 
a moderate quantity is beneficial; there are frequently 
symptomatic indications, calling for considerable. The 
bowels should be kept acting. Improve the tone of the 
stomach and remove dyspepsia, especially flatulence, which 
mechanically interferes with the heart's action. 

3. If there is any constitutional diathesis, as gout or 
syphilis, treatment against this is beneficial. Look to the 
state of the blood ; if there is ancemia, give some preparation of 
iron. Other tonics are useful, as quinine and mineral acids, 
strychnine or tincture of mix vomica, if there is degeneration 
of the heart or want of tone. 

Therapeutic observations have been made the last few 
years as to the effects of certain agents upon the heart. 
Digitalis renders the ventricular contractions more powerful 
and complete, less frequent, and more regular. 

Several other remedies influence the heart, as aconite, 
belladonna ; both are valuable in calming this organ, when it 
acts excitedly and violently ; hydrocyanic acid, veratria, 
caffeine, scoparium, squill, etc. Some of these require to be 
given cautiously, as they are powerful agents. 

5. Do we possess any means of restoring the heart to its 
normal condition when in a state of disease, and is it desirable 



382 GENERAL TREATMENT. 

to use such means'? As regards valvular disease, it is useless 
to attempt to influence these by any therapeutic measures. 
As to the diminution in size of a hypertrophied heart, this is 
not to be aimed at; it is doubtful whether it can be affected in 
the least. Our object should be to maintain the nutrition of 
the heart, and prevent it from becoming dilated. We have 
no means of influencing dilatation, except by improving the 
tone and vigor of the heart by food, tonics, digitalis, etc. It 
is possible that the nutrition of & fatty heart may be improved 
by good diet, tonics, and cod-liver oil. 

6. Symptoms arise in the course of a case of heart disease, 
demanding relief. These are pain and other unusual sensa- 
tions, 'palpitation, angina pectoris, and syncope. Abnormal 
sensations are relieved by wearing a belladonna plaster, or 
using belladonna liniment. The treatment of the other 
symptoms has been pointed out. Palpitation, attended with 
dyspnoea, is quieted by subcutaneous injections of (gr. 1-12 to 
i) of morphia, which relieve spasm of the arterioles, this 
giving rise to the palpitation (Fothergill). Aconite, in 
minute doses, is recommended by Ringer and others. Pul- 
monary symptoms require the usual methods, but are greatly 
relieved by acting on the heart by digitalis. Needless cough 
should be subdued; it is necessary to promote expectoration. 
Cardiac dyspnoea may be influenced by digitalis, or may 
require sedatives and antispasmodics. Any cause of it, as 
flatulence, should be got rid of; it is diminished by making 
the patient sit up in bed, removing pressure on the diaphragm. 

Haemoptysis in heart disease should not be rashly stopped; if 
not sufficient to injure the patient, it may afford relief. Local 
remedies are serviceable in heart and lung symptoms, as dry- 
cupping, hot or turpentine fomentations, and sinapisms. 
Some recommend irritation along the vagus nerve, by sina- 
pisms or gentle galvanism. 

Dropsy sets in in most cases of heart disease. Diuretics are 
most beneficial which act upon the heart, and increase the 
arterial tension in the kidneys, as digitalis. Well-diluted gin, 



CARDIAC AFFECTIONS. 383 

Hollands, and whisky are useful diuretics. Vapor, hot air, 
or even Turkish baths, are beneficial when they can be borne ; 
with due precautions they can be persevered in. I have found 
benefit from local baths, as wrapping up the legs in warm 
fomentations, their whole extent, covering them with 
mackintosh. Excite the skin to activity by surrounding the 
patient with hot-water bottles while in bed. Purgation is 
attended with marked benefit, but it requires care on account 
of the depression which may be produced. Frequently it is not 
desirable to check diarrhoea ; this is a method by which the 
vessels unload themselves ; it may continue, provided it is not 
lowering the patient by excessive amount. If cardiac dropsy 
does not yield to proper treatment, acupuncture should be 
resorted to, with great relief. Due regard must be paid to 
position and cleanliness. 

Much difficulty is experienced to procure sleep in advanced 
cases. Opiates, hydrate of chloral, etc., are frequently inad- 
missible, as they would induce a condition unfavorable to 
respiration, and death might follow. Stimulants should be 
given freely under these circumstances. When the patient 
becomes semi-comatose, from carbonic acid poisoning, the 
bladder must be looked to regularly. 

7. Attend to the other principal organs and guard against 
their becoming involved, especially the lungs, kidneys, and 
liver. Every source of cold should be avoided, the slightest 
pulmonary complaint treated. 

Certain Bare Cardiac Diseases. 

Pericardial Hemorrhage. — Blood may be found in the 
pericardium as the result of: 1. Spontaneous rupture, either 
of the heart or a cardiac aneurism; an aortic aneurism; one of 
the coronary vessels; or of vessels in cancerous deposits. 2. 
Injury. 3. Pericarditis, the effusion being more or less 
hemorrhagic. 4. Diseased conditions of the blood, as scurvy 
and purpura. 



384 RARE CARDIAC DISEASES. 

The symptoms indicate loss of blood and interference with 
the heart's action; they vary with the amount of blood present, 
and the rapidity of its accumulation. Sudden death may 
occur. The physical signs are those of pleuritic accumulation. 

Pneumo-pericardium. — Gas is occasionally found in the 
pericardium, either entered from without, or resulting from 
decomposition of fluid ; it may give rise to tympanitic reso- 
nance, and succession-splash, if mixed with fluid. 

Cardiac Aneurism. — A localized dilatation of the walls of 
the heart. It may involve the entire thickness, or the endo- 
cardium and contiguous strata may be destroyed. The size 
and form vary; there are two types, of general and equable 
dilatation of part of the parietes, and the sacculated variety, 
the latter opening into the heart by a wide or narrow orifice. 
Stratified fibrin or coagulated blood is found in the sac; it may 
be completely obliterated and cured. The left ventricle 
which is invariably affected, and more than one aneurism may 
be present. 

Cardiac aneurism is the consequence of structural change in 
the ventricular walls, fatty or fibroid inflammation, softening, 
rarely ulceration or rupture of the endocardium, or hemorrhage 
into the walls. It is formed gradually, but may be developed 
suddenly from violent strain. Death may occur from rupture; 
there are no reliable symptoms or signs. 

Degenerations and New Formations in the Walls of the Heart. 
— 1. Softening of tissue in low febrile conditions, typhus, 
typhoid, small-pox, scarlatina, and septicaemia. A form of 
simple softening has been described, chronic in its course. 2. 
Fibroid infiltration, or degeneration, or cirrhosis. This is local- 
ized, in the musculi papillares; it may form scar-like patches 
in the walls. 3. Calcification. 4. Syphilitic grovrfhs. 5. 
Albuminoid degeneration. 6. Cancer, which is extremely 
rare, being usually medullary and nodular. 7. Tubercle, also 
very rare. 8. Parasitic formations, as the cysticercus cellu- 
losus, and echinococcus. 

Rupture of the Heart. — Various structural changes have 



CYANOSIS. 385 

been found in the cardiac walls inducing a rupture. The 
more important morbid conditions are, fatty disease, degener- 
ation; great dilatation; cardiac aneurism; abscess or gangrene; 
ulcerative or other destruction of the endocardium; hemor- 
rhage into the walls; calcification; and parasitic formations. 
Rupture may occur in aortic aneurism or coarctation. It is 
induced by some exciting cause, and is much more frequent in 
males and old persons. 

The size, shape, and other characters of the rupture vary 
considerably; more frequent in the left ventricle, but 
traumatic rupture is more common on the right. The 
direction of the laceration is parallel to the chief fibres of 
the heart. 

The symptoms vary according to the mode in which the 
rupture takes place, and its dimensions. Death may be 
instantaneous, or very rapid after sudden insensibility, pre- 
ceded by a shriek. If this does not happen, the important 
symptoms are sudden extreme pain in the cardiac region, with 
oppression and dyspnoea, signs of intense shock and collapse, 
and interference with the cardiac action. Patients occasionally 
rally, and there may be repeated attacks, supposed to indicate 
rupture of successive layers of the heart's fibres. It is stated 
that recovery may take place. 

The treatment of these conditions must be conducted on 
general principles. 

Malformations of the Heart and, Great Vessels — 
Cyanosis — Blue Disease. 

The term cyanosis indicates a certain appearance presented 
by a patient ; it is observed in most cases of malformation of 
the heart, and it applies to these ; it is associated with other 
affections also. 

Etiology. — The pathological causes of cardiac malforma- 

2S* 



386 CYANOSIS. 

tions are either arrested development, or endocarditis or 
myocarditis occurring during intra-uterine existence; more 
common on the right side, with the pulmonary orifice; in very 
exceptional instances, may be acquired after birth, due to 
rupture of a septum. 

Anatomical Characters. — The chief morbid conditions 
in the heart and great vessels, in the class of congenital mal- 
formations are: I. Cardiac. 1. Patent foramen ovale, or 
absence of the auricular septum. 2. Perforation, or incom- 
plete development of the ventricular septum. 3. Owing to 
these conditions there may be but one auricle or ventricle, or 
an aaricle and ventricle are thrown into one, or scarcely any 
separation between any of the cavities. 4. Extreme small- 
ness of the right ventricle, the septum being too much in this 
direction, or cicatricial thickening and stricture. This is rare 
on the left side. 5. Constrictive disease of the tricuspid 
orifice, or contraction of the valves, leading to obstruction or 
regurgitation. 

II. Great Vessels. 1. Incomplete development of the 
pulmonary artery. 2. Constriction of the aorta. 3. Trans- 
position of the arteries, the aorta coming from the right 
ventricle, and the pulmonary artery from the left. 4. Both 
vessels may spring either entirely or partially from the same 
ventricle, due to displacement or imperfection of the septum. 
5. Occasionally there is but one trunk, which comes from a 
single ventricle, and then divides into two. 6. The ductus 
arteriosus is often pervious. 

Some of these conditions are met with together, the neces- 
sary consequences of each other. The common malformation 
is constriction of the pulmonary orifice, with an open foramen 
ovale, and a pervious ductus arteriosus, through which the 
blood passes from the aorta into the pulmonary artery, some 
of it reaching the lungs through enlarged bronchial arteries. 
If the aorta is closed, the foramen ovale and ductus arteriosus 
remain open ; the blood is conveyed by the latter from the 
pulmonary artery into the aorta. 



CYANOSIS. 387 

Symptoms. — They disturb the circulation in one or more of 
three ways: 1. Allowing a free intermixture of venous and 
arterial blood. 2. Interfering with its passage into the lungs, 
while the venous system is overloaded; or with its return 
from these organs. 3. Making the systemic circulation 
entirely venous, the pulmonary entirely arterial, the arteries 
are transposed. Some of the conditions are incompatible with 
life any length of time. In other cases patients may live up 
to twenty or more; the symptoms may not show for a con- 
siderable time after birth ; they are those of deficient blood- 
oxygenation, and general venous stagnation, presented in 
these cases in their most intense degree. Discoloration may 
be blue, leaden, purple, livid, or of a claretty hue, mottled, 
very marked in the lips, ears, fingers, and toes. It is intensi- 
fied by anything which increases the difficulty in the circula- 
tion, such as crying, coughing, etc.; it is the combined effect 
of intermixture of venous and arterial blood, venous stasis, 
and imperfect, arterialization. Fits of palpitation, extreme 
irregularity, and a disposition to syncope or coma. Dyspnoea, 
cough and other lung symptoms are frequent. 

The physical signs vary according to the morbid con- 
dition. If the orifices or valves are affected, there will 
be corresponding murmurs ; pulmonary murmur is com- 
mon. A patent foramen ovale cannot give a murmur. 
In time hypertrophy and dilatation or degeneration is 
observed. 

The duration of congenital cyanosis is very variable; 
it sometimes linger, becoming accustomed to its 
semi-asphyxiated state. Death is never sudden, usually 
gradual. 

Treatment. — Attend to hygienic measures, including 
moderate exercise, baths with friction, and wearing warm 
clothing, flannel next the skin ; give plenty of good 
food, of a hydrocarbonaceous kind, a small quantity of 
alcoholic stimulant ; and treat anything calling for special 



388 DISEASES OF BLOODVESSELS. 

attention. Iron and other tonics, with cod-liver oil. A dry, 
warm climate, and every source of cold avoided. 



CHAPTEE X. 

DISEASES OF BLOODVESSELS. 

Arteritis. — Inflammation of Arteries. — Atheroma, &c. 

Acute arteritis is observed in the aorta (aortitis), and occurs 
in the course of blood-affections more frequently than is 
recognized. Characterized anatomically by injection of the 
vasa vasorum, thickening and softening of the coats, cloudi- 
ness and loss of polish of the inner surface, rough from 
fibrinous deposit. 

Symptoms. — Pain, sometimes extreme, tenderness, or 
superficial hyperesthesia ; heat and throbbing; severe consti- 
tutional disturbance and restlessness; a tendency to syncope, 
and dread of death. The physical signs are objective pulsa- 
tion, occasionally a thrill and murmur, synchronous with the 
cardiac systole. In the smaller arteries inflammation might 
lead to plugging; a clot may be the cause of inflammation. 

Chronic Arteritis is an important morbid process; is the 
origin of atheroma, preceded by a parenchymatous inflamma- 
tion of the inner coat (endarteritis deformans). 

Etiology. — The chief causes of atheroma are: 1. Local 
injury from distention of, and strain upon, an artery, thus 
produced by hypertrophy of the heart. 2. Constitutional 
diseases, as gout, rheumatism, syphilis. 3. Abuse of alcohol. 
4. Senile degeneration. 

Anatomical Characters. — The deep layers of the inner 
arterial coat become infiltrated with new cells, softened, 
relaxed, and thickened. The cells are mainly derived from 



ARTERITIS, ETC. 389 

proliferation. As the result, thickened patches or more 
extensive tracts over the inner surface of the artery, and two 
forms are described : soft, jelly-like, moist, and pale-reddish ; 
and more firm, semi-cartilaginous raised patches, translucent, 
but more opaque in the deeper layers, compared to boiled 
white of egg. The superficial coat is unaffected, and can be 
stripped off. Fatty degeneration beginning in the superficial 
layers, in the cartilaginous variety in the deeper layers. In 
some cases, very rapid, owing to the abundance of cells ; a 
yellowish, soft, pultaceous substance is formed, like a greasy 
paste, giving rise to a pseudo-abscess or atheromatous pustule, 
which may burst into the artery ; at first, a small hole in the 
inner coat, the soft contents pass and are carried away by the 
blood ; finally an atheromatous ulcer is formed, varying in size 
and depth, even involving the middle coat. The softened 
material consists of broken-down fibres, granular cells, 
abundant fat granules, and crystals of cholesterin. Where 
the process is chronic, the substance is firmer, becoming 
caseous ; or organization occurs ; fibroid thickening ; always 
some degeneration. Ultimately calcification is liable to happen, 
or actual ossification, hard, depressed plates being originated, 
or smaller arteries involved and converted into rigid 
tubes. The calcareous plates are at first covered by the 
superficial portion of the lining membrane, liable to give 
way, leaving a rough surface exposed, upon which fibrin is 
very apt to be deposited. 

The vessels affected and the extent vary widely ; different 
stages are usually seen in the same case. Most marked in 
parts of the vesels subject tojthe greatest strain ; in the ascend- 
ing and transverse portions of the arch of the aorta; around the 
opening of arteries which come off laterally, as the intercostals. 
Atheroma is more advanced in the aorta than in the arteries 
generally. 

Fatty Degeneration of Arteries. — Fatty degeneration 
is a distinct process from atheroma. It begins in the superfi- 
cial part of the inner coat, may extend into the middle. The 



390 



epithelial and connective-tissue cells are changed, filled with 
fat-granules ; in the middle coat the muscular fibres undergo 
degeneration. The usual appearances are of small, scattered, 
irregular, opaque, yellowish-white patches, quite superficial, 
slightly projecting, easily removed, leaving normal tissues 
underneath. As deeper layers become involved the patches 
appear more opaque and irregular, and are less easily stripped. 
In time complete destruction and softening, nothing but fat- 
granules remaining, carried away by the blood, leaving 
irregular, superficial erosions. Finally calcification. The 
capillaries are liable to fatty degeneration. 

Occasionally a large artery undergoes simple atrophy, the 
walls becoming thin. 

Symptoms and Effects. — 1. The elasticity of the arteries 
is diminished, finally lost, their resistance increased, and 
ultimately converted into rigid tubes, the calibre diminished. 
Hence an obstacle which leads to hypertrophy of the left 
ventricle, followed by degeneration. The circulation is im- 
paired, disturbance of the cerebral circulation, giddiness and 
alterations of the special senses. Owing to the impairment of 
nutrition, structures undergo degeneration prone to inflam- 
mation from slight causes. 2. When the vessels are rough on 
inner surface fibrin is deposited from the blood, ultimately 
causing complete obstruction. As a consequence, softening 
or death of a part may ensue, as is well seen in chronic soften- 
ing of the brain and dry gangrene of the lower extremities. 
3. A portion of an artery, after the formation of an atheroma- 
tous ulcer, is prone to yield gradually, and thus an aneurism 
be produced. 4. The. aifected vessels become brittle, calcified, 
easily ruptured, causing cerebral apoplexy. 5. Fragments of 
the degenerate structures, or of fibrinous deposit, may be 
detached, carried away by the blood-current, and lodged in 
some smaller vessels as emboli. 6. Physical examination of 
the vessels affords the best indication of their condition, and 
the brachial artery, just above the bend of the elbow, is that 
which can be most readily observed. On bending the elbow, 



THOEACIC ANEURISMS. 391 

the artery is distinctly visible, tortuous, having a vermicular 
motion with each pulse, and it feels hard, full, incompressible. 
A sphygmograpkic tracing is characterized by the large dimen- 
sions of the curves ; the approximation of the secondary waves 
to the summit ; and the great size of the -first secondary wave 
as compared icith the aortic, which is much diminished. 

AVhen the arch of the aorta is extensively diseased, a jerk- 
ing impulse may be observed above the sternum, occasionally 
a thrill ; a rough systolic murmur may also be heard along the 
course of the vessel, or a cardiac basic murmur is intensified 
in this direction. The vessel somewhat dilated; this will 
increase the signs mentioned. 

Diagnosis. — Degeneration of arteries in persons advanced 
in years is a probable cause of many symptoms of which they 
complain. Examination of the vessels is the means of diag- 
nosis, and if the general arteries are affected, probably the 
aorta is in the same condition. Some attach considerable 
importance to the sphygmographic tracing as revealing an 
early stage of degeneration. 

Peognosis. — This involves a knowledge of the dangers 
which accompany degeneration, so that they may be guarded 
against. Many live to a good old age, with the vessels much 
diseased, but at any moment there is a liability to dangerous 
lesions. The earlier the degeneration the more serious is the 
case. 

Teeatment. — All that can be done is to avoid everything 
which is likely to throw a strain upon the vessels, and main- 
tain the nutritive activity of the system as much as possible 
by diet, tonics, and cod-liver oil, the last being decidely useful. 
Any constitutional diathesis mut be attended to, and all inju- 
rious habits checked. 

Thoeacic Aneueisms. 

Aneurisms come under the care of the surgeon; for a full con- 
sideration of the subject reference must be made to surgical 



392 TH0EAC1C ANEURISMS. 

works. It is intended to allude to the main practical facts of 
aneurisms within the chest, especially aortic. 

Etiology. — Aneurism results from morbid change in 
the walls of the artery, as chronic endarteritis, and the athero- 
matous changes thus produced, but also sometimes fatty de- 
generation or simple atrophy. Its determining cause is some 
violent exertion, throwing a sudden strain upon the weak 
portion of the vessel, and may lead to a rupture of part of its 
coats. 

Aneurism is more common among males, whose occupation 
entails violent efforts; about the middle period of life. It is 
frequent in the army; is attributed to the combined effect of 
great exertion; tight clothing, compressing the neck and chest, 
obstructing the circulation; and heavy accoutrements. The 
diseases which predispose to changes in the vessels are 
syphilis, gout, and rheumatism; especially the first. 

Anatomical Characters. — The varieties of aortic aneu- 
rism are: 1. A general dilatation of the whole circumference,, 
either cylindrical, fusiform, or, globular. 2. Sacculated aneu- 
rism is the most important, a lateral bulging or sacculation, 
the coats either entire {simple or true), or the inner and middle 
coats destroyed {compound or false). Sometimes all the coats 
give way, and the aneurism is bounded by surrounding struc- 
tures {diffuse). 3. In exceptional cases a dissecting aneurism. 
The ascending portion of the arch is most frequently affected, 
on the convex side, where it is exposed to strain; an aneurism 
may exist on any part. Great variety in size, shape, contents, 
and other characters. 

Symptoms. — Not uniform, due to pressure, and influenced 
by situation, size, form, rapidity of formation, and direction of 
growth, liable to alter during progress. The symptoms are 
not in proportion to the external physical evidences of aneurism; 
the reverse is often true, as the more an aneurism tends inwards 
the more severe are the symptoms; they may be extremely 
aggravated. 

A bulging in front of the chest, in which pulsation is felt, 



THORACIC ANEURISM. 393. 

not continuous or identical with that of the heart, and over 
which resonance upon percussion is dull — is probably an 
aneurismal tumor. If a thrill is also perceptible in it, with or 
without a murmur on auscultation, we may be still more 
confident in the diagnosis; and when the signs of pressure 
upon the air tubes, oesophagus, sympathetic or recurrent 
laryngeal nerve,or throracic duct occur, it is nearly certain. 

Murmur may, however, be absent; so may thrill; the 
bulging may be slight, and the percussion resonance little 
altered. The sign of most consequence is, the existence of 
two points of pulsation in the chest, the cardiac and the 
aneurismal; the latter coinciding almost with the diastole of 
the heart. 

The signs of pressure are chiefly, pain, cough, dyspnoea,, 
loss of voice, difficulty of swallowing; and emaciation from 
obstruction of the thoracic duct. 

Cancerous or other tumors may produce all these latter 
signs ; but such tumors do not pulsate. In empyema the beat 
of the heart sometimes impels the fluid so as to throb rather 
widely; but this is still a single cardiac impulse. Occasion- 
ally a consolidated lung, in phthisis, may vibrate forcibly, 
with the pulmonary artery; but other signs then make clear 
the disease. 

The course of aortic aneurism is usually very gradual — 
often lasting for a number of years. Death occurs — 1, from 
sudden rupture and copious hemorrhage; 2, from slighter 
rupture and slow leakage; 3, from slow exhaustion by pres- 
sure, interfering with respiration, deglutition, etc. 

Treatment. — The first object in treatment is promoting 
coagulation of a sacculated aneurism. Failing this, protect it, 
retard its development and treat the symptoms and complica- 
tions. 

To induce a cure, rest in the recumbent posture for a 
considerable time, and avoid every source of mental disturb- 
ance. A careful regulation of diet, a definite quantity of 
solids and liquids, at stated intervals. The exact amounts 



394 MEDIASTINAL TUMORS. 

depend upon each individual case; everything should be 
strictly weighed or measured, the object being to support life 
with as little food and drink as possible, without inducing 
nervous irritability. Excess of fluid avoided, all stimulants 
prohibited. 

Medicinal agents may be employed ; those which calm and 
regulate the heart's action, such as digitalis, aconite, or bella- 
donna; and those which promote coagulation, particularly 
gallic or tannic acid, tincture of steel, and iodide of potassium. 

Keep the aneurism covered with cotton ; should it be 
prominent, some kind of protecting shield might be worn. 
For relieving pain and procuring sleep, the chief remedies are 
hyoscyamus, lactucarium, hydrate of chloral, and conium. 
Subcutaneous injection of morphia is valuable. External 
applications are belladonna or opium plaster ; belladonna or 
aconite liniment ; cold poultices of linseed-meal and vinegar, 
of conium, digitalis, or oak-bark (Walshe) ; ice, ether-spray, 
or chloroform cautiously applied ; counter-irritation by flying 
blisters or iodine, which sometimes gives marked relief. If 
there are severe laryngeal symptoms, evidently due to pressure 
on the recurrent nerve, it is justifiable to perform tracheotomy. 
It has been suggested that in some cases the sterno-clavicular 
ligaments might be divided, in order to allow displacement of 
the clavicle forwards. 

Mediastinal Tumors. 

Aortic aneurism is the most frequent form of mediastinal 
enlargement. The other chief varieties are cancer (either 
encephaloid or scirrhoencephaloid) originating in the oesopha- 
gus, glands, root of lung, or thymus gland; fibro-cellular, 
fibrous, or fibro-fatty tumors ; enlarged masses of glands in 
tuberculosis, or Hodgkin's disease; inflammatory exudation 
and abscess ; or rarely masses of steatoma, or hair. 

Symptoms and Signs. — Mainly those of pressure, as 
already mentioned, and present the usual variations ; " currant 



MEDIASTINAL TUMORS. 395 

jelly expectoration is said to be common in cancer. There 
may be constitutional symptoms of this diathesis. The physi- 
cal signs of a solid tumor are widely different, bnt the following 
list may give some notion of those to be sought for. 1. Local 
bulging in front of variable extent, often irregnlar, not pulsat- 
ing. This may be absent. 2. Deficiency or absence of respira- 
tory movements over the seat of enlargement ; in some instances 
over one side, from pressure on a bronchus. 3. Altered 
percussion-sound, being dull and toneless, hard, wooden, and 
high-pitched, occasionally tubular or amphoric ; with marked 
resistance. 4. Respiratory sounds weak or absent, blowing, 
or tubular, according to the relation of the enlargement to the 
main tubes. 5. Vocal fremitus and resonance either deficient 
bronchophonic, or pectoriloquous. 6. Frequently dry and 
mucous rales in the bronchi. 7. Displacement of the heart and 
other structures ; increased conduction of the heart-sounds • 
occasionally a murmur from pressure on a great vessel. 

Diagnosis. — Mediastinal tumor has to be distinguished 
from other morbid conditions in the chest; chronic 
pneumonia, chronic pleuritic effusion, pericardial effusion, and 
enlargement of the heart. Careful consideration of the history 
of the base, its symptoms, physical signs, and progress, will 
rarely leave doubt as to the diagnosis. It is more difficult to 
determine the natrue of mediastinal enlargement. In the 
diagnosis of any doubtful case, as between aneurism and a 
solid tumor, usually cancerous, the following conditions have 
weight : 1 . A female under 25 points to a solid tumor ; the 
family history may suggest ajcancer ; or the occupation favor 
aneurism. 2. Symptoms, dysphagia, severe pain, especially 
behind, are more common in aneurism ; oedema of the arm and 
chest, frequerit haemoptysis, and especially currant-jelly expec- 
toration, in tumor. Occasionally cancer-elements may be 
discharged in the sputa. 3. The physical signs are of much 
value. The limitation of these to the region of the aorta, 
presence of any thrill, double impulse with doubling of the 
diastolic share, and gradual approach of any pulsation to the 



396 INFLAMMATION OF THE BE A IN. 

surface, are suggestive of aneurism ; great superficial extent of 
dullness, absence of heaving character in the pulsation, the 
want of accordance between it and the maximum dullness, are 
in favor of tumor. 4. Examination may reveal cancer in 
other parts, or constitutional evidence of its presence. 

Treatment. — All that can be done is to relieve symptoms 
as they arise. 



CHAPTER XI. 

DISEASES OF THE BRAIN AND NER VO US SYSTEM. 
Inflammation of the Beain. 

Synonyms. — Encephalitis, Phrenitis, Meningitis, Cerebritis. 
The last two are not technically identical ; but not clinically 
separable. Inflammation of the membranes derives its import- 
ance from the implication of the brain. 

Varieties. — Simple and scrofulous encephalitis or meningo- 
cerebritis. 

Simple Meningo-Cerebritis (meningitis). 

Symptoms. — Intense headache, redness of face and eyes, an 
excited look, dizziness, roaring in the ears, extreme sensitive- 
ness to light and sound, restlessness, wakefulness, wild 
delirium. Vomiting is common; the bowels are usually 
costive. Late in the attack in adults, at any period in 
children, convulsions may occur. Rigidity of the muscles is 
frequent in bad cases; paralysis often follows convulsions. 

Stages. — These are generally described as three. 1. That 
of active congestion and inflammation ; with hot, hard, rapid, 
full, regular pulse, morbid sensitiveness to light and sound, 
headache and delirium. 2. That of commencing effusion and 
cerebral oppression; with more moderate heat of the surface 



INFLAMMATION OF THE BKAIN. 397 

stupor, aud sloiv or irregular pulse. 3. That of cerebral 
disability or disorgauization ; with unconsciousness, convul- 
sions, muscular rigidity or paralysis, and rapid, feeble pulse. 

Morbid Anatomy. — Except in traumatic cases the dura 
mater rarely takes part in the lesions of encephalitis. Bather 
minute hypersemic injection is found here and there in the 
arachnoid membrane; sometimes opacity and thickening occur, 
with adhesions. In the pia mater, generally with considerable 
increase of redness, serum has been effused; or even pus. The 
pia mater adheres firmly to the brain. The ventricles contain 
more serum than usual ; sometimes several ounces. In some 
cases it is turbid, flocculent, or purulent. The brain itself is 
most frequently affected, with redness in the convolutions, and 
dots of blood in the medullary portion ; also, with softening 
in the gray or white substance, or in both. 

Diagnosis. — The distinctions between simple and tuber- 
culous or scrofulous meningitis or encephalitis will be con- 
sidered. Typhoid fever, delirium tremens, and acute mania 
may be mistaken for inflammation of the brain. 

Typhoid fever does not usually have vomiting, long-con- 
tinued headache, or morbid sensibility to light among its 
symptoms; while tympanites, diarrhoea, bronchitic cough, etc., 
make it known. In delirium tremens, the origin of the affec- 
tion in alcoholic excess, the most horrible illusions, tremor 
and insomnia, without headache, are characteristic. Acute 
mania is almost or quite without fever ; often without head- 
ache ; and the muscular strength is little impaired ; vomiting, 
also, is absent. 

Subacute or chronic encephalitis, now and then met with, 
presents greater difficulty in distinguishing it from mania. 
The best authorities state that cerebral hyperemia and inflam- 
mation bear an important part in the pathology of insanity. 
(See Winslow on the Brain and Mind.) 

Children afford frequent instances of another question in 
diagnosis — how far symptoms affecting the brain may or may 
not depend upon the stomach for their causation. "Gastric 



398 INFLAMMATION OF THE BRAIN. 

fever" and "infantile remittent" are phrases applied often to 
to attacks occurring in childhood or infancy; in which, with 
indigestion and vomiting, there is delirium, stupor, or apathy, 
with or without convulsions. In such cases, the heat of head 
and fullness of the carotid and temporal arteries are less, the 
gastric disorder, fur of tongue, etc., greater, than in cerebral 
inflammation. Cholera infantum is often attended by brain 
symptoms; but its other features, the time of year, and 
locality are distinctive. 

Prognosis. — Simple encephalitis, under good treatment, is 
not always fatal; but a majority of cases end in death. 

Causation. — Between fifteen and forty-five is the age 
most subject to this disease. Males are more liable than 
females to it. Hot climates predispose to it; and so does 
intemperate living. Exciting causes are, blows or falls upon 
the head, exposure to the sun, violent or prolonged mental 
excitement, erysipelas of the head, scarlet fever, metastasis of 
rheumatic or gouty inflammation, repulsion of eruptions upon 
the skin, suppression of accustomed discharges. Extention of 
inflammation from the ear (otitis) to the brain is a possibility, 
important not to be overlooked. 

Treatment. — Purging actively is important; by sulphate 
or citrate of magnesium, or, if dosing be difficult from 
delirium, elaterium and euema. After one free purging, 
moderate catharsis may be, if necessary, repeated every two or 
three days; and the bowels should be kept open during the 
attack. 

Cutting the hair short, or, still better, shaving the whole 
head, will aid in giving relief, and will allow the effectual 
application of cold. Pounded ice, in a bladder or bag of 
India-rubber, will do if watched and changed in place often, 
to prevent too great an impression upon one part. Many 
prefer a linen cloth (as a cambric handkerchief) folded once, 
dipped in ice water, and laid over the head; it should be wet 
freshly every few minutes, or the good effect is almost lost. 
Merely wetting the head now and then with cold water 



TUBERCULAR MENINGITIS. 399 

produces a reaction not a sedation, which is required. If the 
feet be cold, they should be made warm by mustard foot-baths 
or sinapisms. In children the prolonged warm bath may be 
useful. Evaporating lotions are often better applications to 
the head. 

The diet in the first part of the attack should be as light 
and unstimulating as possible. Oatmeal gruel, panada, rice, 
toast- water may come first ; then milk, chicken- water, 
mutton broth ; later, beef-tea and nourishing diet. 

Blisters are serviceable after the intensity of the inflam- 
matory excitement has begun to diminish. The best will be 
a blister to the nape of the neck and between the shoulders. 
It need not remain on many hours. 

In a late stage, with secondary debility, concentrated liquid 
diet, with alcoholic stimulants, and even opiates at night, may 
be required to support the flagging energies of the system. 

Convalescence in the best cases may be slow. The faculties 
may remain feeble, and the brain morbidly excitable, for 
weeks or months, needing great care as to all mental impres- 
sions and efforts, lest a dangerous relapse occur, or chronic 
cerebral hyperemia, perhaps insanity follow. The case must 
be looked after until well. 

Tubercular Meningitis. 

Acute Hydrocephalus. — From two to fifteen years is the age 
most apt to yield examples of this fatal disease. Premonitory 
symptoms usually occur ; dullness, pettishness, and languor ; 
headache ; disposition to put the head in the mother's lap, or 
to lie down ; loss of appetite, vomiting, and costivness. The 
child sleeps ill, with grinding of the teeth, or sudden starting 
with alarm. After four or five days, constant headache and 
anxiety of countenance, heat of head, sensitiveness to light, 
fever and drowsiness, alternated with moaning or occasional 
screaming, and delirium at night, mark the case. 

Advanced symptoms are, total stupor, strabismus, con- 



400 HYDROCEPHALUS. 

vulsions, and paralysis. The pulse goes through similar 
changes to those of simple encephalitis ; first febrile accelera- 
tion, then irregularity and slowness, lastly the rapidity of 
moribund prostration. The attack terminates on the average 
in between two and three weeks. 

Prognosis is always unfavorable in this disorder. 

Morbid Anatomy. — Since Papavoine, Kufz and Gerhard 
showed the existence of a relation between tuberculosis and 
" acute hydrocephalus/' autopsic inquiry has proved fully : 1. 
That tubercle-like granulations, with opacity and thickening 
of the arachnoid at the base of the brain, adhesion between 
the hemispheres, and serous effusion characterize a number of 
the cases. 2. That all of these lesions may be found without 
any tubercle whatever ; and 3. That the amount of such 
deposits in most cases is not sufficient to modify greatly the 
course of the local disease, at least in such a manner as 
tubercle acts elsewhere. 

It is concluded, hence, that it is rather the diathesis than 
the deposits that make the disease to differ, as in progress and 
prognosis it clearly does, from simply meningitis or en- 
cephalitis. 

Treatment. — Purge moderatively, not exhaustively ; 
blister the back of the neck ; apply cold with care, or what is 
better, evaporating lotions, as alcohol, or ether and water, and 
allow liquid nourishment, such as milk and beef-tea, mutton 
or chicken broth, etc., from an early stage. Iodide of potas- 
sium is recommended by some practitioners, other diuretics 
and alteratives. 

Hydrocephalus. 

Definition. — Water in the head; dropsy of the brain. 
This is almost always an affection of early life. Sometimes it 
is congenital. It is mostly a passive dropsical effusion ; cer- 
tain cases show signs of a chronic or subacute inflammatory 
condition of the arachnoid membrane. 



SOFTENING OF THE BRAIN. 401 

Symptoms. — Languor, strabismus, convulsions, loss of 
appetite, increase in the size of the head. This last may be 
•enormous ; the fontanels expanding, and, in a slow case, the 
bones growing excessively large. The mental faculties nearly 
always grow dull. Bodily emaciation and debility attend. 

Although cases are known and recorded in which hydro- 
iephalic persons lived for more than twenty years, the general 
rule is that they die in a few months ; either from cerebro- 
spinal disability or atrophy, or from some intercurrent disease 
not endurable by the impaired vital energies of the system. 

Treatment. — Small as is the encouragement given by 
experience in this affection, it is certainly justifiable to try 
measures not out of place in themselves. Such are, moderate 
purging, every few days, or once a week, sustaining the 
strength by nourishing food, and, if it be borne, cod-liver oil; 
diuretics; shaving the head and rubbing it nightly with iodide 
of potassa ointment ; occasionally blistering the back of the 
neck ; in a child preferably, by painting it with cantharidal 
collodion. Pneumatic aspiration may perhaps prove useful in 
hydrocephalus, to remove the fluid gradually and safely. 

Softening of the Brain. 

Pathologists generally recognize two forms of this: 1. Acute 
red inflammatory softening; and 2. Slow, white, atrophic 
softening or degeneration of the brain-substance. Both 
receive the name of ramollissement. 

The former of these is further definable as a local cerebritis; 
whose symptoms are not nearly always separable, clinically, 
from those of meningitis or encephalitis, already described. 
Cadaveric inspection shows not only hy perse mic redness and 
softening, but, sometimes, abscess, or even gangrene of the 
brain. This last is probably always the result of injuries. 
Induration of the brain may also follow traumatic inflamma- 

*29 



402 SOFTENING OF THE BRAIN. 

tion of the brain. The cerebrum is more often affected with 
red softening than the cerebellum. 

Abscess of the brain is in a certain number of cases latent 
for a considerable time. Sudden headache is apt to be the 
earliest symptom. This is attended by feverishness, vomiting, 
difficulty of speech, numbness, convulsions, paralysis, and 
coma. Otitis and pycemia are said to be, after injuries, the 
most frequent direct causes of it. 

Diagnosis. — Acute Red Softening. — The occurrence of 
imperfect coma, with rigidity of the muscles of the extremities, 
or of paralysis without loss of consciousness, will make 
probable this lesion. Most cases die within two weeks ; some 
within two or three days. 

White atrophic softening or degeneration of the brain may 
take place as a result of old age, or from intense mental labor 
or excitement, from intemperance, or from embolism; that is,, 
obstruction of an artery within the brain by a fibrinous clot 
carried from some other part. Its approach and progress are 
more slow and insidious than those of acute inflammatory 
ramollissement. Neuralgic pains in the limbs, followed by 
numbness and paralysis; general debility, and dullness of the 
senses, gradually increasing to blindness, loss of hearing, etc., 
and a corresponding decline of the mental powers ; these are 
the usual symptoms, which may be extended over a period of 
many months. Death is sure to be the final result. 

Treatment. — If inflammatory red softening can be diag- 
nosticated at an early period, a similar treatment to that named 
for acute meningo-encephalitis may be advised. Local deple- 
tion, at least, followed by counter-irritation by blisters, may 
be resorted to in a case which appears to K be such; the more 
freely, because apoplexy, which most nearly simulates it, 
presents very similar practical indications. 

Chronic atrophic white softening is not amenable to any such 
measures; nor, indeed, to any active remedial treatment. 
Prevention, by the avoidance of its causes, and palliation or 
economy of the waning powers of the system, are alone possi- 



INFLAMMATION OF THE SPINAL MARROW. 403 

ble. The management necessary under such indications must 
vary with every case. 

Inflammation of the Spinal Marrow. 

Clinical Synonyms. — Myelitis, Spinal Meningitis. The 
symptoms of this uncommon affection are, constant and severe 
pain in the back, increased by motion; spasmodic contractions 
or rigidity of the muscles followed by paralysis, fever, consti- 
pation of the bowels, and retention of urine. Authors state 
that in myelitis proper, as distinguished from spinal arachnitis, 
there is no pain nor muscular rigidity, but only paralysis of 
motion and sensation. 

Morbid Anatomy. — Diffuse redness and opacity of the 
arachnoid, swelling and infiltration of the pia mater, and 
effusion of serum, communicating freely with the cavity of the 
cranium, are generally found. Adhesions of the membranes 
from plastic lymph are less common; and still less so, though 
repeatedly recorded, is suppuration within the arachnoid. The 
dura mater is occasionally affected with inflammation, and 
even ulceration and gangrene, commencing from without. 
The cord may be reddened from injection of its substance, and 
softened ; more rarely indurated in parts. 

Treatment. — Cooling evaporating applications along the 
spine, followed by a blister, and active purgation with saline 
cathartics, constitute the essential parts of the treatment of 
simple inflammation of the spinal cord or of its membranes. 
If the diagnosis be doubtful, the practice must be dispropor- 
tionately less bold; this is, of course, a principle of very 
general application in therapeutics* 

Epidemic cerebrospinal meningitis has been considered as 
Cerebrospinal fever. 

Apoplexy. 

Definition. — Sudden coma, produced neither by injury 
nor by poison. 



404 APOPLEXY. 

Varieties. — Some terms once used have been shown to be 
without pathological justification; as serous apoplexy, nervous 
apoplexy. Good authority still sustains, however, the mention 
of two forms at least of genuine apoplectic seizure ; congestive 
and hemorrhagic. 

Symptoms. — Congestive Apoplexy. — Premonitory symptoms 
often seen are, flushed appearance of the face and eyes, heat of 
head, throbbing of the carotids, distension of the temporal 
arteries and jugular veins; constipation, languor, dullness, 
drowsiness; dimness of sight, vertigo, headache. The attack 
is marked by sudden stupor; with slow and sometimes snoring 
respiration, full and slow pulse, dusky or turgid appearance of 
the face. The total loss of perception may be brief, its partial 
absence or deficiency continuing for some time. Slight con- 
vulsive movements are not uncommon. Paralysis of the 
muscles occurs only for a short time after the attack, if 
recovered from. 

Hemorrhagic Apoplexy. — Generally no clear premonition is 
given; the attack being very sudden ; a stroke, literally. Un- 
consciousness is complete, for some seconds, minutes, or hours. 
After this, general or local paralysis, most often hemiplegia, is 
left; the mental powers also, in many cases, being impaired at 
least temporarily. During the coma, the breathing is com- 
monly stertorous, and the pulse slow, and somewhat full, the 
head hot, the face more or less dark or flushed. But the full- 
ness of the bloodvessels and heat of the head are much less, as 
a rule, than in congestive apoplexy. 

Anatomy and Pathology. — In the congestive form, 
excessive cerebral hyperemia produces coma by pressure upon 
the brain ; the extremest degree of which (vascular pressure) 
is met with in strangulation. 

In hemorrhagic apoplexy, from the rupture of a degener- 
ated artery, either in the substance of the cerebrum or 
cerebellum, in the ventricles, or under the arachnoid mem- 
brane, effusion of blood occurs, and a clot is formed. If this 
be small, it may be gradually absorbed ; autopsic inspection 



APOPLEXY. 405 

sometimes shows the remains of such, where another hemor- 
rhage has caused death. Fatty degeneration of the arteries of 
the brain has been repeatedly, but not always observed ; and 
miliary aneurisms of the cerebral arteries have been often 
noticed, by Charcot and others. 

The age of the clot may be ascertained in part by the dis- 
covery, with the microscope, of blood-crystals ; which are not 
found until after seventeen or eighteen days from effusion. 

Diagnosis. — Apoplexy is to be distinguished from uraemia, 
alcoholic intoxication (dead drunkenness), narcotic poisoning 
(as from opium), compression of the brain, or concussion, from 
blows or falls, asphyxia (suffocation), sunstroke, catalepsy, 
cerebral hysteria, acute softening of the brain, and spotted fever 
or "cerebro-spinal meningitis;" as well as from all forms of 
syncope. From ursemic coma it is only to be known by the 
history of the case, showing a renal origin for the symptoms,, 
in partial or total suppression of the urine. Alcoholic intoxi- 
cation is revealed by the odor of the breath, and the attendant 
circumstances. Similar aid exists sometimes in cases of 
narcotic poisoning; in opiate narcotism, moreover, the pupil is 
contracted; in that from most other narcotics, it is as firmly 
dilated. Concussion and compression of the brain are gener- 
ally suggested by the position of the body (if found without a 
history), and the external marks of injury. Asphyxia also is 
usually pointed out by the condition of things surrounding the 
patient. 

In asphyxia, blueness of the lips, and embarrassment of 
respiration, with coldness of the surface, show the origin to be 
in the function of breathing. Sunstroke is attended by 
feebleness of the pulse, at least in the majority of cases; in 
some, it is, identically, a congestive apoplexy. In catalepsy, 
there is rigidity of the muscles, with rapidity of the pulse, 
susceptibility of the pupil to light, brief duration and repeated 
recurrence of the attack, without any paralysis. Cerebral 
hysteria is rare, and occurs only in females, whose previous 
disorders of the nervous system will aid in interpreting even 



406 APOPLEXY. 

coma as belonging to the same category. Acute red softening 
of the brain may be very difficult to distinguish from apoplexy. 
It is, however, seldom if ever so sudden in its invasion; there 
is more slobbering or flow of saliva, and watering of the eyes ; 
and there is not the partial or entire restoration of the faculties 
which an attack of apoplexy, not fatal, allows so often. 
Spotted fever, or "eerebro-spinal meningitis," is especially 
described, and its diagnosis considered, in another place. 

Syncope, of any form or origin, is marked by pallor, coldness, 
and loss of pulse. 

Peognosis. — This is always alarming; most so when there 
is the most reason to believe that cerebral hemorrhage has 
occurred; and, therefore, especially those advanced in life. 
In younger subjects, where stertor of breathing is absent, 
under proper treatment, congestive apoplexy may be entirely 
recovered from. So may a single attack of the hemorrhagic 
form, with a small clot only, and limited, transient paralysis. 
Each succeeding attack becomes more dangerous; a third is 
seldom survived. The immediate danger connected with an 
attack of apoplexy should not be considered over for ten days 
at least after the stroke itself. Very seldom, indeed, after a 
hemorrhagic attack, are the mental or bodily powers so good? 
for the rest of life, as before. 

Causation. — Age is the most constant promotive cause of 
apoplexy. Cases are on record, though of extreme rarity, in 
children; between thirty and fifty it is much more frequent; 
but after fifty it is one of the most common modes of death. 
Arterial degeneration is here the general occasion of the 
catastrophe; some mental excitement, or bodily shock or 
effort, as danger, or joy, or a few glasses of wine, or the stoop- 
ing posture, or straining at stool, causing a rupture of the 
weak vessel, and fatal cerebral hemorrhage. Neither sex 
seems to be more liable to this disease than the other. 

Full living, especially with alcoholic intemperance (even 
moderate) and indolent habits, predispose to it in a marked 
degree. So does excessive brain work. Florid, short-necked, 



APOPLEXY. 407 

big-bellied people are most exposed to it. Hypertrophy of 
the left ventricle of the heart is believed to promote it. After 
dinner and during sleep are the two most likely times for the 
attack to occur. 

Treatment. — The younger the patient, and the more 
vigorous his antecedent health, the more probable is the 
existence of the congestive form; and, also, the better the 
prospect of recovery from hemorrhage within the cranium, if, 
only, the effects of pressure be averted at the time. If, then, 
in a person under fifty, not before of broken constitution, we 
find the head hot, face turgid and flushed, the arteries and 
veins of the neck and temples full, the pulse also strong, and 
the heart 9 8 impulse so (or the heart's action vigorous though 
the pulse at the wrist be oppressed) blood may be taken, by 
cups or leeches applied to the back of the neck. 

Older or more doubtful cases may be treated tentatively, 
with cups alone, aided by mustard plasters to the legs, back, 
and epigastrium in turn ; with laxative injections into the 
rectum during the attack, and saline purgatives afterwards. 
The head should be kept raised, and cooled with wet cloths or 
evaporating lotions until its temperature becomes normal. If 
the hair be thick, it should be cut very short or shaved off 
entirely. 

When, however, there is reason, as usually is the case in 
really old or broken-down patients, to believe that structural 
degeneration, arterial or that of ramollissement, is the source of 
the attack, loss of blood will be out of place. Such cases, if 
they survive the first apoplectic fit, require rather nourishing 
diet, and sometimes even tonics, to support strength, favor 
repair, and prolong life. Great delicacy of judgment is 
necessary in deciding in different cases between these appar- 
ently so opposite modes of treatment. The tendency of 
medical opinion, for the last twenty years, has been toward 
the curtailment of the use of any depletion in apoplexy. 

Where a moderately plethoric condition is present, and the 
taking of blood, generally or locally, is not decided upon, 



408 APHASIA — PARALYSIS. 

purgation is safe and likely to be useful. Jalap, resina 
podophylli, or croton oil, in small doses, will have the 
advantage of convenient administration. 

Aphasia. 

I 

Loss of speech may occur as one of the symptoms of disease 
of the brain, either functional and transient, or organic and 
irremovable. Such a loss of language is termed aphasia. 
Importance has been given to it lately by the observations of 
Trousseau and others, and resulting speculations (Dax P. 
Broca) as to the seat of the faculty of speech. Not articulation, 
as in aphonia, but expression is, in this affection, wanting. 
The power to write words from memory, to convey meaning, 
is lost; but, in some cases, at least, they may be copied 
correctly. Thinking without words may go on in such in- 
stances ; as Lordat recorded, after recovery, in his own case. 

Hemiplegia of the right side has in a number of examples 
coincided with aphasia; and, several times, also, autopsy has 
shown softening or other lesion of the left anterior portion of 
the cerebrum. On the suggestion of these facts a hypothesis 
has been based, that the site of the faculty of language is in 
the third anterior frontal convolution of the left hemisphere of 
the cerebrum. This is a very unphysiological supposition, in 
view of the symmetry of the cerebro-spinal axis throughout; 
nor does this objection disappear even upon the conjecture 
that the "organ" upon the right side may exist always in an 
undeveloped state. Valvular lesion of the heart sometimes 
accompanies this disease. 

Cases of aphasia are rare. There are no special measures of 
treatment for it pointed out as yet by experience. 

Paralysis. 

Varieties. — According to the proximate cause: 1. Cerebral 
palsy; 2. Spinal ; 3. Reflex paralysis ; 4. Toxsemic (e. g., lead 
palsy); 5. Hysterical palsy. According to the extent of the 



PARALYSIS. 409 

affection : Facial or other local palsy; Hemiplegia; Paraplegia; 
General paralysis. According to its nature: Motor (acinesia), 
and Sensory paralysis (anaesthesia). 

Facial Palsy. — This is an affection of the portio dura of the 
seventh pair of cephalic nerves, the motor nerve of the face. 
It occurs at any age, usually from rheumatoid inflammation of 
the sheath of the nerve at its escape from the cranium through 
the stylo-mastoid foramen. One side of the face is without 
change of expression ; and the eye on that side is not closed 
(in severe cases) from the paralysis affecting the orbicularis 
palpebral muscle. The tongue is not affected in the move- 
ments. 

The facial motor nerve is not often involved in the much 
more serious cases of cerebral palsy. Absence of disturbance 
or of incompleteness of control over the tongue, while the 
power over the eyelid is partly or wholly lost, with the 
absence also of severe cerebral symptoms, will, especially in a 
young person, make the diagnosis easy as well as important. 
The prognosis is, generally, of recovery in a few days or 
weeks. The treatment of this form of local palsy may be by 
repeated small blisters behind the ear; followed, when 
convalescence has begun, by some warm covering (cotton wad- 
ding, flannel, or silk) to protect the part from cold. 

Other Local Palsies. — Pressure upon a nerve may cause its 
paralysis, generally temporary. A man has been known to 
have his hand rendered powerless for three weeks by sleeping 
all night with his arm bent under his head. Frictions, the 
endermic application of strychnia, and galvanism may be used 
in such a case. Writer's cramp, or scrivener's palsy, is the 
result of exhaustion of certain muscles from over-use. Its 
cure is rest and friction. 

Palsy of the optic nerve is designated as amaurosis ; of the 
sense of hearing, cophosis ; of taste, ageustia; of smell, anos- 
mia. Except the first, however, these terms are not much 
used. 

Hemiplegia. — Brain-lesion is most often the cause of this 



410 PARALYSIS. 

affection; either an apoplectic clot, a tumor, or softening. 
Spinal disease may, however, produce it; and some cases are, 
by writers upon the subject, referred to a peripheral .or reflex 
origin. There may occur, also, sometimes transiently, epileptic, 
choreic and hysterical hemiplegia. Owing to the decussation 
of the anterior pyramids of the medulla oblongata, lesion of 
one side of the brain produces motor paralysis of the other 
side. In spinal lesion the palsy is usually on the same side. 
Brown-Sequard, however, has shown decussation of the sen- 
sory nerves in the cord; and he explains the symptoms in 
some cases thereby. 

Symptoms — Suddenly, almost always, but not always with 
loss of consciousness, the patient loses the power of motion, 
and more or less of sensation on one side. In complete cases, 
the parts involved are the arm and leg, the muscles of mastica- 
tion (with the buccinator), and half of the tongue. In trying 
to protude the tongue it is pushed out towards the affected 
side ; in retracting it, the reverse happens; that is, it is drawn 
towards the sound' side. The palsied cheek hangs; but the 
eye can be shut or opened at will. The third, fifth, and ninth 
nerves are especially apt to show implication by disturbance of 
the actions under their control; of the fifth, those of the 
muscles already mentioned, as well as of facial and lingual 
sensation ; of the third, loss of power to lift the eyelid, 
strabismus, and dilatation of the pupil ; the ninth, one-sided 
movement of the tongue, affecting also the speech. 

Hemiplegia may be attended either by rigidity or relaxation 
of the muscles ; and the former may be early or late. Where 
there is decided relaxation in cerebral paralysis, it is probable 
that white softening, or atrophy from embolism of the brain, 
is the lesion, with or without a clot ; where early rigidity is 
marked, an apoplectic clot may be inferred. Late rigidity is 
probably due to an atrophic state of the muscles ; a " rigor 
mortis invito," Contradictory accounts are given by authori- 
ties as to the susceptibility to galvanic excitation of the 
muscles on the sound and on the paralyzed side. It is 



PARALYSIS. 411 

probable that the loss of excitability of the muscles is in pro- 
portion to their atrophy. 

The prognosis in hemiplegia depends greatly on the ascer- 
tainment of its causation. If it follows an epileptic fit, or 
attack of chorea, or occurs in a hysterical subject, it may be of 
comparatively brief duration, ending in recovery. If an 
apoplectic attack precede it or if any lesion of the brain be 
inferred from the history of the case, the prospect is bad. 
Partial improvement may occur, not often entire restoration ; 
and renewed attacks or " strokes " are likely to follow. 

Treatment. — Essentially the same principles are applicable 
to this as have been mentioned in connection with apoplexy. 
The younger the patient, the more vigorous his or her previous 
health, and the fuller the circulation, the more appropriate 
may be the local abstraction of blood, to diminish pressure 
upon the brain. Where softening is apprehended, exceptional 
and cautious. Epileptic, choreic, and hysterical hemiplegia 
indicate no depletion. Rest, regulation of the bowels, and 
counter-irritation by dry cups to the upper part of the spine, 
and afterwards a blister ; with frictions, as with brandy and 
red pepper, or whiskey and hot water, or salt and spirits, to 
the affected limbs ; these are measures of general utility. An 
issue on the back of the neck is sometimes recommended. As 
to strychnia, it is not safe where cerebral or spinal irritation is 
likely to exist, as near the commencement of most attacks. 
Even at a late stage it should be used with extreme caution, 
watching its effects. Precisely the same statement may, upon 
the best authority, be made as to electricity, in cerebral 
paralysis. In the hysterical form, if it last long, electricity 
may be applied locally, with safety and advantage. In any 
curable case, passive exercise of the weak limbs will be very 
useful; also moderate friction. 

Paraplegia. — This is paralysis of both the lower extremities. 
Spinal disease or injury is its source ; with or without cerebral 
implication or complication. It may come suddenly or 
gradually ; generally its beginning, at least, is sudden. Reflex 



412 PARALYSIS. 

paralysis, as described by several authors, is sometimes 
paraplegic. 

Symptoms. — In organic or spinal paraplegia, as well as in 
the reflex form, numbness in the feet and pain in the back are 
apt to be early signs. The power of motion is lessened or 
lost in the lower limbs. The muscles may be either relaxed 
or contracted. The lesion of the spinal marrow, if progressive 
is productive finally, in many cases, of loss of power over the 
bladder and sphincter ani. Bed-sores, with deep ulceration 
and sloughing, may occur in protracted cases. 

Treatment. — When myelitis is believed to exist, at an 
early stage, local depletion to a moderate extent, in otherwise 
good subjects, may be advised. In any case, counter-irrita- 
tion (not vesication, in a bedridden patient, unless he can lie 
well on either side), by repeated sinapisms, or stimulating 
liniments, will be proper. 

While inflammation, or active irritation of the spinal cord is 
made apparent by the symptoms (pain, cramps, muscular 
twitchings, or rigidity), strychnia is not suitable. After these 
have subsided, it may be given — not more at first than the thirti- 
eth of a grain twice daily. If it produce jerking movements 
of the hands or feet, or nervous restlessness, or any marked 
uneasiness, it should be suspended. Electricity may be used, 
with similar caution, in a secondary or relatively late stage of 
paraplegia. Moderate (at first very gentle) shocks of the 
interrupted circuit are preferred. 

Hysterical Paralysis.-— In females this is among the many 
forms of functional disorder which that strange and not yet 
clearly defined disorder, hysteria, may produce. It is diag- 
nogticated by the aid of the history of the patient. D*. Todd 
stated that, in it, the affected limb (it is most often hemiplegic) 
in walking, is dragged after the other, as if a dead weight ; 
while in cerebral hemiplegia the palsied leg and foot are 
brought round in a curve, the body being bent toward the 
sound side at the time. 

Treatment. — Tonics, good nourishment, and change of 



PARALYSIS. 413 

air (in a word, analeptic management), are most needed in 
nearly all hysterical cases. For the paralysis itself, electricity 
has been found useful. Mild shocks for a few minutes twice 
a day may be given with the magneto-electric apparatus. 

Reflex paralysis. — Since Stanley's paper (1833), asserting the 
production of paralysis, sometimes, by disease of the kidney, a 
number of medical writers have added to the list of supposed 
cases of " paralysis without apparent lesion." Worms, dysen- 
tery, diarrhoea, uterine, irritation, teething, and external 
injuries are all thought to induce reflex paralysis in certain 
instances. Diptheritic and scarlatinal palsies have by some 
been placed in the same category. The simplest and clearest 
cases are those of wounds. 

The pathology of this form of palsy is a subject of much 
controversy. The best explanation is that of Handfield Jones 
and S. W. Mitchell ; expressed in the term proposed by the 
former — " inhibitory action." In other words a morbid im- 
pression, from injury or disease, in one part of the body, being 
transmitted along a nerve to a nerve-center, overwhelms or 
paralyzes it ; this effect being shown, of course, in the parts to 
which it distributes nervous branches. 

Treatment. — In true reflex paralysis, of short or moderate 
duration, the removal of the irritant cause produces instant 
relief; as in H. Jones' case, where strabismus from palsy of 
the external rectus occuli muscle disappeared after a piece of 
dead bone was extracted from a whitlow on the thumb ; or 
Lawrence's, in which blindness of one eye (of thirteen months' 
standing) was cured by the extraction of a carious tooth, with 
a splinter of wood projecting from one of its fangs. When 
the nature of the case does not admit of such prompt relief, if 
the diagnosis be clear, the same indication remains; to address 
our remedial measures to the seat or source of peripherial 
irritation. Palliate, if we cannot cure, the trouble there, and 
we will obtain palliation, if not relief, of the reflex disability. 
Electricity has proved signally useful in the subesequent 
treatment. This form of disorder is very rare. 



414 PARALYSIS. 

Diphtheritic Paralysis. — After the termination of an attack 
of diphtheria, commonly within three weeks, the muscles used 
in swallowing and speaking, less often those of the upper and 
lower limbs, and the sense of sight, may be partially paralyzed. 
Loss of sensibility usually accompanies the loss of motor 
power. This condition of things may last for weeks, or even 
months, but is generally recovered from. Whether the 
immediate cause of the paralysis is the peripheral lesion of 
the nervous terminations (in the pharyngeal and laryngeal 
affection) or the toxsemic influence, upon the nerve-centres, of 
the morbid poison of diphtheria, cannot yet be decided. In 
extended palsy as a sequela, the latter is the more probable 
explanation. 

Treatment.— Passive exercise, stimulating frictions, and 
electricity, sometimes with change of air, and general toning 
of the system, are suitable measures for this affection. 

Syphilitic Paralysis. — The most unequivocal instances of 
this nature are accounted for by periostitis within the cranium, 
involving the dura mater, or, by nodular exostosis, pressing 
upon the brain. The most remarkable fact connected with 
such cases is the recorded experience showing the prompt 
curative effect upon it of iodide of potassium. Obscure paralysis 
without apoplectic symptoms, and in a syphilitic constitution, 
may be tentatively so treated, on the basis of such experience, 
on general principles. 

Lead Palsy. — Considerable time of exposure to the influence 
of lead is generally necessary to cause this. So commonly 
does it first affect the extensor muscles of the forearm, that the 
cognomen of "wrist-drop" is often applied to it. When it 
lasts for some weeks, the muscles waste away. A blue line is 
observed to form along the edge of the gums. Pain precedes 
the palsy, and attends recovery of power. During the attack, 
the muscles have their excitability by electricity considerably 
diminished or lost. 

Mostly, after a long time, lead palsy is recovered from. 
Iodide of potassium appears to act as an eliminant of the lead 



PAUALYSIS. 415 

accumulated in the system. Ergot is asserted by some to be 
curative also. Faradaic electricity has been found decidedly 
beneficial ; used in moderate strength for a few minutes two 
or three times a day. 

Mercurial Palsy is met with in those who work in the 
metal. Mostly tremor is a predominant symptom. Early 
withdrawal from the influence of the cause, and the continued 
use of the iodide of potassium, are the principal measures of 
treatment. 

Paralysis agitans, or shaking palsy, is described as a more 
or less constant involuntary and uncontrollable shaking of the 
hands, arms, head, or, progressively, of the whole body. 
Slight or moderate degrees of such tremor are common enough, 
from general nervous debility. Extreme cases evince the 
wreck of the cerebro-spinal system, and are therefore incurable. 
No special treatment can be pointed out for this affection. 

Wasting Palsy. (Cruveilhier's) — A few of the muscles of 
one limb, or the voluntary muscles of the whole body, may 
lose their power, and then waste away almost to nothing. The 
shoulder and the ball of the thumb are frequent points of com- 
mencement for the palsy and atrophy. Insidious in its 
approach, the affection may last from six months to several 
years. It may end in recovery, in permanent arrest at a 
certain stage of the disease, or in death. Twelve months is 
the earliest recorded period for the occurrence of a fatal end. 
This end is the result always when the trunk is invaded. 
After death, the spinal marrow has been examined in but a 
few cases. No lesion has been found in most of them ; in a 
certain number it has. But our methods of inspection of 
nervous tissue are yet too imperfect for it to be pronounced 
that such an atrophic disease is independent of the nervous 
centres. It may be the ganglia which regulate nutrition that 
are in fault. 

General Paralysis of the Insane. — Only a minority of insane 
persons have this affection. Delusions of an extravagant kind 
commonly attend it. Difficulty of speech, and general tremor, 



416 LOCOMOTOR ATAXIA, ETC. 

characterize it, followed by the gradual loss of all muscular 
and sensory power. By the use of the ophthalmoscope, 
atrophy of the optic nerves has been frequently detected in it. 
It is incurable. 

Locomotor Ataxia. Duchenne's Disease. 

Rheumatoid pains, in this affection, precede loss of power. 
Occasional strabismus and incontinence of urine may occur. 
Then there is an awkward, unsteady gait ; the sensibility of 
the feet becomes blunted, and walking is insecure. If the 
patient shuts his eyes, he falls down, and even with them open 
he reels as if drunk. The duration of this progressive disease 
varies from six months to ten or twenty years. It is most 
common in males of middle age. That this is a spinal affec- 
tion is obvious. Sclerosis of the posterior columns of the 
cord has been several times found after death. In its treat- 
ment — hygienic management, general tonics, electricity, and 
very careful use of strychnia, may be tried, without much 
hope. 

Epilepsy. 

Definition. — Periodical convulsions, with unconscious- 
ness during the attacks. 

Varieties. — Grand mal and petit mat of the French; the 
latter is the eclampsia minor of some writers; in which 
unconsciousness occurs with little or no convulsion. 

Symptoms. — Premonition occurs in a minority of case s 
before an attack; headache, dizziness, terror, spectral illusions, 
or the epileptic aura. This is a creeping or blowing sensation, 
like that of a current of air or stream of water, beginning in a 
hand or foot, and extending toward the trunk. It (if it occur) 
immediately precedes the paroxysm. Then, often with a 
•scream, the patient falls down, and is violently convulsed. 
Foaming at the mouth, grinding of the teeth, and biting of 
the tongue, are common ; the face is flushed, the eyeballs roll. 



EPILEPSY. 417 

the pupils are unaffected by light, sometimes vomiting, or 
involuntary urination or defecation takes place ; and respira- 
tion may be very laborious. 

The fit lasts on an average from five to ten minutes. The 
interval between the attacks may be from several months 
down to a few hours. Old cases (as in lunatic asylums) may 
have two or three paroxysms daily. They vary much even in 
the same individual. 

The condition after the attack is also various. Generally, 
drowsiness or deep sleep follows it; or headache, debility, or 
delirium; sometimes maniacal frenzy. Homicide has been 
committed in this state; for which, of course, the person is 
not criminally responsible. 

Anatomy and Pathology. — Epilepsy is not often the 
immediate cause of death. Autopsies of epileptics (Schrceder 
van der Kolk) have shown changes especially in the medulla 
oblongata; dilatation of the bloodvessels being prominent. 
Exaggeration of reflex motor excitability, with loss of the 
controlling power of the brain over the spinal axis, would 
seem to be parts, at least, of the morbid condition. Marshall 
Hall's idea of "trachelismus," or temporary partial asphyxia 
from spasm of the muscles of the neck, has been exploded. 
Brown-Sequard's theory of the importance of the aura, as 
indicating a peripheral irritation at its seat, has, after causing 
the tentative amputation of a few limbs, suffered the same 
fate. 

Diagnosis. — From hysterical convulsions, which also may 
be periodical and violent, those of epilepsy are distinguished 
by the total loss of consciousness, which is partially retained 
during the hysterical paroxysm. Curability belongs also 
much more to the latter than to the epileptic disease. 

Prognosis. — Few cases of genuine epilepsy recover. The 
younger the patient, and the longer the interval, the more 
hope. Life may last indefinitely with the disease. Gradually, 
in most cases, the mental faculties are impaired. 

30* 



418 CATALEPSY. 

Causes. — Hereditary transmission of this disease is com- 
mon. Intemperance, venereal excess and self-abuse, blows on 
the head, and fright, are among the most frequent exciting 
causes. 

Treatment. — During the paroxysm, when habitual, little 
or nothing is to be done. Place the patient so that he cannot 
strike his head or limbs against anything hard; loosen the 
clothing about the neck to favor free respiration and circula- 
tion ; and insure fresh air about the patient ; that is all. An 
occasional convulsion requires treatment; of that more will be 
said hereafter. (See Convulsions.) 

To break up the recurrence of the fits is the problem, for 
which a vast number of remedies has been tried in vain. To 
name them would be to go over almost half the materia 
medica. Prominent, since nitrate of silver was generally 
abandoned as useless, in this disease, have been belladonna, 
arsenic, valerianate of zinc, digitalis, and bromide of potas- 
sium. 

Self-management is very important to the epileptic. 
Temperance, with nutritious diet, as the disease is one of 
asthenia, is necessary. Regularity of the evacuation of the 
bowels is a sine qua non. Abundant exercise in the open air, 
short of exhaustion, does good ; systematic gymnastics have 
even cured some cases. They are worth trying always. 
Avoidance of, or the extremest moderation in sexual inter- 
course must be insisted upon. Self-abuse will make recovery 
impossible. Tobacco ought not to be used. As the attacks 
may come very suddenly, prudence is necessary, to avoid 
serious accidents. 

An issue kept on the back of the neck is well worth trying 
in every case. 

Catalepsy. 

This is a periodical disease, in which the attack is marked 
by unconsciousness, and fixed rigidity of all or many of the 



CONVULSIONS. 419 

voluntary muscles. It is rare. The attack generally lasts 
but a few minutes. Sometimes, in lunatics, a semi-cataleptic 
state of the muscles is permanent. 

There is no special treatment appropriate for this affection. 
Management like that suitable for the epileptic will be in 
place also in catalepsy. Both are now so well understood to 
be asthenic disorders, with impaired hcematosis (blood-making) 
as an important element, that all reducing measures are 
properly omitted from their treatment. This must be 
essentially tonic and analeptic or restorative in every 
particular. 

Convulsions. 

These may be classified as infantile, epileptic, parturient and 
puerperal, hysterical and occasional convulsions. 

During infancy, causes which in an adult would cause deliri- 
um produce convulsions; excito-motor action having in early 
life the predominance. They are, usually, of less serious prog- 
nosis^ the infant than in the adult. 

The exciting causes of infantile convulsions are numerous. 
-Constipation of the bowels ; indigestion ; worms ; irritation of 
the gums in teething; and excitement of the brain, as by 
fright, are about the most frequent. Many acute and chronic 
diseases of infancy (as scarlet fever, meningitis, whooping- 
•cough, etc.) have convulsions among their occasional symp- 
toms or complications. Sudden drying up of eruptions on the 
scalp may bring them on, also. 

. Premonition of a fit is often observed, in the child's fretful- 
ness, or restlessness, or gritting of the teeth in sleep. When 
a fit comes on, the muscles of the face twitch, the body 
becomes rigid at first, then in a state of twitching motion ; the 
head and neck are drawn backward, the limbs violently flexed 
and extended. Sometimes these movements are confined to 
certain muscles, or are limited to one side. Nurses call by 
the name of "inward fits" cases in which the limbs move but 



420 CHOREA. 

little, but the countenance is affected, the eyes are unnatural 
in expression, or roll spasmodically, and the body is more or 
less rigid. Sometimes one attack is followed by another, with 
intervals of conscious or unconscious quiet between, for many 
hours. These are the most serious cases, although recovery 
often happens even from them. Salaam convulsions, or 
nodding convulsions of infants (eclampsia nutans), are a 
rare form of disease, usually the precursors of epilepsy. 

Treatment. — Ascertain, if possible, the cause of the con- 
vulsion. If the gums are swollen, or have been tender and 
irritated, at the time of teething, lance them freely ; dividing 
the tense gum with a sharp gum-lancet down to the coming 
tooth. If the bowels have not been moved, or if the abdomen 
be swollen and tense, give at once an enema, of castor oil,, 
soap, and molasses, or some other laxative material, with 
warm water. When the head is hot, apply cold water all 
over it, by wet cloths, renewed every two or three minutes. 
If the fit lasts long enough for it, place the child in a warm 
bath; supporting, of course, the head while the body is> 
immersed. Then mustard plasters may be applied, to the 
back, epigastrium, and legs, at once or successively. 

Cupping the back of the neck, in some cases where time is 
allowed by a protracted fit, may be resorted to ; especially dry 
cups. 

Etherization, so much used by some practitioners in 
puerperal convulsions, requires more caution in its use ini 
infants. It is less used in the convulsions of childhood ; but 
it may be regarded as justifiable in an obstinate case at any 
age; watching its effect. If swallowing is interrupted, use 
antispasmodics with enema, as chloral, lobelia, etc. 

Chorea. 

Synonym. — St. Viim' Dance. 

Symptoms. — Incessant and irregular movements of the 
voluntary muscles, over which the will has but partial 



CHOKEA. 421 

control. Walking, in severe cases, is difficult or unsafe; the 
hands cannot be regulated enough to write or work ; speech 
may be affected; the muscles of the face often twitch gro- 
tesquely. During sleep all these movements cease. The 
pupil is, in some cases, unnaturally dilated ; palpitation of the 
heart may occur ; and also constipation and indigestion. The 
urine is of great density. 

Prognosis. — The mean duration of chorea is about four 
weeks; but it may last for several months. Recovery, if the 
attack be uncomplicated, may nearly always be anticipated. 

Complications. — Endocarditis and pericarditis have been 
observed in connection with chorea in a number of cases. 
Generally, however, the affection of the heart precedes the 
chorea; both probably depending on the same cause, 
rheumatism. 

Paralysis complicating chorea increases greatly, of course, 
the seriousness of the case. Although it may be of the 
transient, hysterical form, yet the danger exists that it may be 
the result of organic lesion (as softening) of the brain or spinal 
cord. 

Causation. — From six to sixteen, in both sexes, especially 
often in girls, chorea occurs. Nervous debility is almost 
always present before the attack. Fright is a frequent cause. 
Over-fatigue, or mental excitement, blows or falls may pro- 
duce it. Rheumatic fever is sometimes followed by it. 

Treatment. — Good diet, salt bathing, and systematic 
gymnastic exercises (light gymnastics or calisthenics) will 
suffice for mild cases. Where marked ansemia exists, iron 
(citrate, phosphate, or pyrophosphate, tincture of chloride, 
syrup of iodide) is important. Obstinate cases may be treated 
with Fowler's solution of arsenic, in small doses, gradually 
increased. Cimicifuga has been a good deal used, perhaps 
with benefit. Cod-liver oil should be given if great debility 
exist. Calabar bean has recently been introduced as a remedy 
in chorea; gtt. v to f3ss of the tincture, or from gr. j to gr. vj 
of the powder thrice daily. 



422 TETANUS. 

It is well to separate a child having severe chorea from 
other children; both because of the annoyance of their 
curiosity, and because sympathetic irritation sometimes extends 
the affection from one to another. This has been repeatedly 
observed. 

Tetanus. 

Definition. — A disease characterized by continued tonic 
contraction of the voluntary muscles generally. 

Symptoms. — Stiffness of the muscles of the jaws commonly 
begins the attack. This extends to the throat and neck, face, 
trunk, and lastly to the limbs. Though never ceasing 
entirely, the spasm of the muscles is paroxysmally increased. 
Sometimes opisthotonos occurs, i. £., arching of the body upon 
the back and heels, the abdomen projecting; or emprosthotonos, 
arching forward, the face approaching towards the toes. 
Pleurosthotonos, or lateral curvature, is much more uncommon. 

Chewing of food is impossible ; swallowing nearly or quite 
so ; respiration becomes very difficult. The patient suffers 
dreadfully, and cannot sleep ; but delirium scarcely ever 
occurs. Death in most cases takes place within a week. 

Varieties. — These are, tetanus from cold (idiopathie), 
traumatic tetanus (from an injury), and trismus nascentium, or 
tetanus of infancy. The first is the least certain to be fatal. 

Causation. — This is principally included in the above. 
Much the greater number of cases results from lacerated and 
punctured wounds ; but amputations and other operations 
may be followed by tetanus. Irritation (not inflammation) of 
the ends of sensitive nerves, transmitted to the spinal cord, 
produces the reflex spasm, whose general extension and con- 
tinuance prove fatal. Strychnia, in poisonous doses, causes a 
similar state. While there can be no doubt that the spinal 
marrow is the seat of the disease, no characteristic organic 
change has been found in it; sometimes not even congestion. 

Treatment. — A tablespoonful of whisky (to an adult) 
every two or three hours with milk or beef-tea, and a grain of 



HYDROPHOBIA — RABIES. 423 

opium every three or four hours, may be given. The opium 
may be, if needful, increased to a grain every hour at night, 
and every two hours through the day. 

Chloroform and other anaesthetics, by inhalation, nave been 
tried, with variable effec#; nearly always without success. 
Belladonna, aconite, hydrocyanic acid, cannabis indica, 
tobacco, woorara, quinine, hydrate of chloral, and Calabar 
bean (physostigma), are among the many medicines favored by 
different practitioners. In so desperate a disease it is excus- 
able to give them all further trial. I have had good results 
from an antispasmodic enema, keeping the system relaxed. 

Hydrophobia — Rabies. 

Symptoms. — A month or more after the bite of a mad dog 
or other rabid animal, the wound having healed, irritation is 
felt. At first the patient feels despondent, restless, dread, 
giddiness or alternate chills and heats. Then oppression, deep 
sighing inspirations, with severe pain in the epigastrium. The 
subsequent symptoms are : 1. Spasm of muscles of degluti- 
tion and respiration. 2. Extreme sensibility of surface and 
special senses. 3. Excessive mental terror. A fit of choking, 
by an attempt to drink. This condition becomes rapidly 
worse with intense oppression and suffocation. Soon the 
sight or sound of any liquid that suggests drinking brings the 
spasmodic attacks; the patient spits viscid secretion out of the 
mouth as fast as it forms, so as not to swallow it. Special 
senses become sensitive, the least touch, sound or light bring 
on spasms, which extend to other muscles, assuming the 
characters of general convulsions. Fits of furious mania 
occur, the patient is dangerous, utters strange sounds, which 
has given the idea of barking being a symptom of this disease. 
In intervals the intellect is quite clear. Sometimes curious, 
persistent delusions. Towards a fatal termination, the special 
symptoms diminish, or disappear, and the patient sinks from 
exhaustion and collapse. 

Treatment. — Immediately cauterize the part bitten by 



424 NEUKALGIA. 

hot iron or potassa fusa, or complete excision. Other modes 
of preventive treatment are useless. The patient's mind 
should be calmed and be prevented from brooding over his 
danger. There is no remedy, I know, of any real service in 
hydrophobia, once the disease has become developed. 

Neukalgia. 

Neuralgia or nervous pain is an important malady of com- 
mon occurrence and a comprehensive term applied to certain 
painful affections occurring in different parts of the body, the 
pain appearing to follow the distribution of particular nerves 
and having special characters. 

Etiology and Pathology. — Most cases are dependent 
upon some general or constitutional condition. The causes are : 
1. Exposure to malaria. 2. Certain metallic poisons, as lead, 
mercury, or copper. 3. Anaemia or malnutrition and debility. 
4. Depression and weakness of the nervous system, as pro- 
longed worry and anxiety, undue mental exertion, strong 
emotion, concussion of the nervous system, hysteria, fatigue, 
exposure to heat, ennui and luxurious habits, excessive 
venery. 5. Degenerative changes with the decay of life, and 
those which precede locomotor ataxy. 6. Kheumatism, gout, 
syphilis, exposure to cold and wet. 

An important group of causes of neuralgia are local. 1. 
Injury to a nerve, wound, the lodgment of a foreign body, 
when the pain may be in some distant nerve. When a nerve 
is cut, either it or some nerve related to it becomes the seat of 
neuralgia. 2. Pressure by foreign bodies, as a bullet, cica- 
tricial thickenings, old adhesions, neuromata, tumors, aneu- 
risms, enlarged glands, callous uniting fractured bones, 
congested veins, or long sitting, tight boots, hanging the arm 
over a chair. 3. Irritation by necrosed bone, when it passes 
through a foramen or canal, carious teeth, surrounding inflam- 
mation or ulceration, or direct exposure to cold. When 
neuralgia is local its occurrence is influenced by the general 
state of the system, one of debility either general or specia 



NEURALGIA. 425 

Predisposing causes are : female sex ; certain periods of life, 
that of sexual development, and about or beyond middle age ; 
hereditary tendency to nervous affections ; and a nervous 
temperament. An acute attack is intensified by fatigue or 
other lowering influence. It may come on spontaneously, or 
by mental disturbances, pressure, cold, heat, overexercise, etc. 
Neuralgia may be some morbid change in the nerve or 
nerve-centre, or there is no such obvious change. In some 
cases there is congestion or inflammation. Atrophy with de- 
generation of a nerve has been found, due to pressure, often so 
advanced as almost to destroy sensation. In all cases of 
neuralgia there is either atrophy, or a tendency to it, in the 
posterior or sensory root of the painful nerve, or in the central 
gray matter in closest connection. 

Symptoms. — Pain is the essential symptom of neuralgia. 
1. Invariably unilateral. 2. In recent cases intermittent, in 
sudden paroxysms, at irregular intervals, but occasionally at 
regular periods, especially in malarial cases ; later it is remit- 
tent. 3. The pain during the paroxysms is severe, in some 
cases excruciating, as stabbing, piercing, boring burning, 
screwing, shooting from a point along branches of the nerve 
affected, but rarely all ; the darts, twinges, or " tics," in some 
come on with the suddenness of an electric shock, causing 
intolerable agony. The pain may extend to contiguous or 
distant nerves. Strong pressure over the chief point affords 
relief; in other cases gentle friction does this; in others there 
is exquisite tenderness. This paroxysmal pain often ends as 
abruptly as it commenced, with a sense of relief and comfort. 
The pain in the intervals is much less severe, of dull or 
aching character, and in the superficial neuralgias presents 
circumscribed points of tenderness, "points douloureux," corres- 
ponding to the exit of branches of the nerve through bony 
foramina or openings in fibrous membranes, though they 
appear to be more diffused, in some cases the sensation of 
tolerably extensive contusions. 

Interesting complications are : local hyperesthesia, hypses- 



426 NEURALGIA. 

thesia, or paresthesia, as numbness, tingling, or formication * 
disturbances of special senses, especially sight; spasmodic 
twitchings, tonic spasms, convulsive movements, or local 
paralysis ; pallor, followed by redness of the skin, pulsation of 
the arteries, increase in temperature, and swelling of the 
affected part, with subcutaneous oedema; hypertrophy or 
atrophy of the tissues in prolonged cases, or increase of adipose 
tissue ; increased firmness, falling off or whitening of the hair ; 
the breaking out of skin eruptions, as herpes zoster, acne ; 
increased vascularity of the conjunctiva, conjunctivitis, iritis,, 
and other morbid conditions of the eye ; periostitis ; swelling 
or unilateral furring of the tongue ; erysipelatoid inflammation 
of the tissues to which the affected nerve is distributed ; im- 
paired gastric secretion ; increased flow of saliva or tears ; 
local increase of perspiration. 

"Varieties. — Neuralgias are primarily divided into — I. 
Visceral, including Cardiac; Hepatic; Gastric ; Peri-uterine 
and Ovarian; Testiadar ; Renal. II. Superficial, viz., Tic-. 
douloureux; Hemicrania or Migraine; Cervico-occipital ; 
Cervico-brachial ; Intercostal; Mastodynia/ or irritable breast; 
Lumbo-abdominal ; Sciatica ; Crural. The visceral group will 
not be further alluded to, some of them having been already 
considered under their respective organs. The names applied 
to the superficial group will indicate their respective localities, 
but a few of them need special comment. 

Tic-douloureux — Brow-ague — Prosopalgia is a common 
form of neuralgia, the 5th or trigeminal nerve being involved. 
Rarely are all the divisions implicated, and it is the ophthal- 
mic branch which is most frequently affected, the pain being 
chiefly above the orbit and about the temple. Numerous 
points of tenderness, the supraorbital and parietal, the latter 
being just above the parietal eminence, and correspondiHg to 
the inosculation of several branches. A variety of this neu- 
ralgia is named clavus hystericus, in which there is extreme 
pain, as if a nail were being driven into one or more spots^. 
corresponding to the supraorbital or parietal points. 



NEURALGIA. 427 

Hemicrania — Migraine or Megrim — Sick-headache. — Con- 
siderable attention has been paid of late to the complaint 
recognized by the above names. It is considered a form of 
neuralgia, though there is no unanimity of opinion as to its 
nature. Most authorities regard it as independent of any 
morbid state of the alimentary canal, and as essentially a 
nervous affection. Derangements of the abdominal viscera 
have an important influence in causing migraine. The chief 
views are : 1. It is a form of neuralgia of the ophthalmic or 
occipital nerve, or of the filaments distributed to the dura mater. 
I favor migraine being a form of trigeminal neuralgia, pri- 
marily a morbid condition at the root of the nerve in the 
medulla oblongata, its central nucleus being the seat of atrophic 
molecular irritation, which has a tendency to communicate 
itself to nucleus of the vagus. 2. The complaint is due to 
vaso-motor disturbance affecting the vessels of the head, through 
the sympathetic nerve. In the premonitory stage of sick- 
headache, the small arteries are contracted, owing to excite- 
ment of the vaso-motor nerves, which depends upon a weak- 
ening of the controlling power exercised over them by the 
cerebro-spinal system, this originating in the medulla 
oblongata. During the stage of headache the nerves become 
paralyzed, and the vessels dilated; this paralysis is the 
result of depression following excitement. 3. Dr. Liveing 
has the hypothesis, that the paroxysms of migraine are due to 
" nerve-storms, traversing the sensory tract from the optic 
thalami to the ganglia of the vagus, or radiating in the same 
tract from a focus in the neighborhood of the quadrigeminal 
bodies." 

Sick-headache is characterized by periodic attacks, which 
commence during the period of bodily development from 15 
to 25, becoming more frequent and severe, up to a certain 
time, tending to diminish in frequency or to cease in advanced 
age, after the change of life in women. The predisposing 
causes are the female sex, attacks liable to occur about the 
menstrual periods; hereditary tendency to migraine or other 



428 NEURALGIA. 

neuroses; anseinia and general want of tone, a nervous and 
excitable temperament. A paroxysm often comes on without 
exciting cause, or may follow errors in diet, exposure to the 
sun, breathing vitiated air, undue mental excitement or effort, 
fatigue with fasting, sexual indulgence, and other causes of 
physical or mental depression. Sometimes it results from 
disturbance of sight or hearing. 

An attack is ushered in by premonitory symptoms, mostly 
when patient wakes in the morning, as depression, heaviness, 
or general uneasiness, vertigo, disturbed vision, a wavy glim- 
mering, chilliness and shuddering, coldness of the hands and 
feet, tingling in the arm or tongue, irritability of temper, 
yawning, gaping, or sighing, disorder of speech or hearing, 
disinclination for food with a slimy taste. Soon pain com- 
mences and becomes intense. It is unilateral, chiefly in the 
supraorbital region, or in the Orbit, but may extend over the 
whole side of the head. The pain varies much, but is gener- 
ally throbbing. Pressure on the carotid artery diminishes its 
intensity. Heat, often redness of the conjunctiva, with ex- 
cessive flow of tears. During the paroxysm patient takes to 
bed, feels depressed, dreads disturbance, begs to be at rest, 
and is sensitive to light and noise. The pulse is frequently 
slow and soft ; the pupils contracted. When suffering reaches 
its height, nausea and bilious vomiting aggravate the pain 
afterwards it gradually diminishes, and the patient falls 
asleep. Vomiting is not remedial, but indicates the lowest 
point of nervous depression. Vomiting may be beneficial if 
there is much undigested food in the stomach. On awaking 
the pain has ceased, leaving superficial tenderness for a day or 
two. The duration is variable ; an attack does not commonly 
last more than 24 hours, though it may go on for two or three 
days or more. 

Intercostal Neuralgia. — Pain along one or more intercostal 
nerves. There is a constant pain, increased by a deep inspira- 
tion or coughing, or moving the arm. Shooting pains at 
intervals, extending from the spine along the intercostal 



NEURALGIA. 429 

spaces, or from the lateral point backwards and forwards. 
Three very distinct "points douloureux" can be detected, viz., 
I. Vertebral. 2. Lateral, opposite the lateral cutaneous 
branch. 3. Sternal or epigastric, where the anterior cutaneous 
nerve perforates. This variety is common in ansemic and 
chlorotic females. It precedes herpes zoster, and a very 
severe and obstinate form is liable to follow the latter in old 
people. For the diagnosis from pleurodynia or pleurisy, the 
condition of the patient, the want of connection of the pain 
with excessive use of the local muscles, of exacerbation from 
use, or relief from rest, the characters of the pain with the 
points of tenderness, and the results of physical examination, 
are quite satisfactory. The breaking out of herpes is 
pathognomonic. 

Sciatica or Hip-gout is neuralgia in the branches of the 
sciatic and other nerves about the hip. The pain is mainly in 
the back and outer part of the thigh ; may be in various parts 
of the lower extremity, down to the leg or foot ; generally a 
persistent pain near the tuberosity of the ischium, paroxys- 
mally, shooting up or down, either without cause or the 
consequence of pressure, movement, a sudden jerk, or cough- 
ing. The patient obliged to walk carefully, or unable to 
move. Local anomalies of sensation, convulsive movements, 
cramps, and partial paralysis are common. Many cases are 
severe and unyielding to treatment. The limb may waste 
from want of use. 

Causes of sciatica are long-continued sitting, exposure to a 
cold draught, as using windy privies, sitting on a cold or damp 
surface ; frequently it is associated with gout or rheumatism. 

Treatment. — 1. Local cause or irritation must be removed. 
Caution respecting " tic-douloureux." This is often attributed 
to decayed teeth; these are extracted one after another 
without improvement, because neuralgia is not dependent 
upon this cause at all. 2. Those who are subject to neuralgia 
should adopt means to prevent attacks, by attending to diet, 
hygiene, wearing warm clothing, regulating the alimentary 



430 NEURALGIA. 

canal, and promoting general health, .avoiding every cause 
likely to bring on a paroxysm. 3. Treatment directed to the 
general state of the system or to some constitutional diathesis is in 
a large proportion of cases of the highest importance. Fatty 
elements when nutrition is impaired, cod-liver oil or cream. 
Iron in anaemic subjects ; quinine in full doses, in malarial 
neuralgias ; Fowler's solution ; strychnine or nux vomica ; 
valerianate and other salts of zinc, phosphorus, etc. If 
neuralgia be associated with gout, rheumatism, syphilis, or 
metallic poison in the system, treatment directed against such 
a condition is essential. 4. An important class of remedies 
are those which have a direct sedative effect on the nervous sys- 
tem ; opium or morphia; belladonna; extract of cannabis 
indica ; hydrate of chloral ; bromide of potassium ; conium ; 
atropin ; tincture of aconite ; veratria ; and ammonic chloride 
in full doses. Of late, two new drugs said to be very effica- 
cious, viz : eucalyptol, which is an essential oil derived from 
the Eucalyptus globulus; and the tincture of Gelsemium semper- 
virens. These medicines are either internally applied to the 
affected part by plasters, liniments, ointments, tinctures, 
or some of them introduced by subcutaneous injection, as 
morphia and atropin. They are not merely for temporary 
relief, but are important aids in a cure, if employed systematic- 
ally and regularly every day for such a period as the case 
may require. In using subcutaneous injection, begin with a 
small dose — not more than one-tenth to one-sixth gr. of 
morphia —and increase it as occasion requires, some cases need- 
ing large quantities in time. The injection need notbe made at 
the seat of pain, except in advanced cases where there is 
hyperesthesia, and much thickening and hypertrophy exist 
about the nerve. Sensibility may be first blunted by the 
ether spray. 5. Certain anodyne local applications as liniment 
or plaster of belladonna, opium plaster, tincture of aconite, 
ointment of aconitin or veratria, and a liniment containing 
eucalyptol. Dry heat or heat with moisture, chloroform 
liniment, sinapisms, flying blisters, and light linear cauteriza- 



NEUEALGIA. 431 

tion. In obstinate cases blistering and even stronger forms of 
counter-irritation are recommended. Cold is useful in some 
cases, in the form of ice or evaporating lotions, ether spray 
over the seat of pain for a few minutes three or four times 
daily. A valuable local method of treatment now recognized 
is that by electricity. The constant galvanic current is best, 
sometimes faradization is beneficial, or charging the patient 
from a friction-machine, or afterwards taking a spark from 
the seat of pain. In employing galvanism only a very weak 
current, especially about the head, carefully guarding against 
giving rise to unpleasant head symptoms; to apply it by well- 
wetted sponges in the direction of the nerve, the positive pole 
placed over the seat of pain; not make the application for too 
long a time, but frequent repetitions. Surgical interference in 
obstinate cases of neuralgia, the nerve being divided or a 
piece of it cut out. This is rarely -followed by permanent 
good results. 

Migraine during the premonitory stage, the patient should 
go into a quiet, darkened room, and lie down on the side on 
which the pain usually occurs, with the head low, the extrem- 
ities kept warm. Many remedies are recommended; their use- 
fulness differs in different cases. The most important are 
diffusible stimulants, as a little brandy or sherry and soda- 
water, champagne, or spirits of ammonia; a cup of simple 
strong tea or coffee; hydrate of chloral; tincture of cannabis 
indica; bromide of potassium ; nitrate of ammonium ; caffein, 
either internally or by subcutaneous injection; and the now 
fashionable guar ana powder, which consists of the powdered 
seeds of the Paulinia sorbilis. This last drug is given in the 
dose of TO to 15 grains; there is contradiction in the accounts 
of different observers as to its efficacy. The application of a 
weak continuous galvanic current is sometimes useful. Warm 
foot-bath containing mustard, and to breath the steam from 
this at the same time. In some cases the administration of an 
emetic, as ipecac, has been decidedly beneficial in my experi- 
ence. Much relief often results from tightly binding the head 



432 DELIRIUM TREMENS. 

with a wet bandage. Probably the steady application of ice 
or the cold douche might be serviceable in cases. During the 
height of an attack leave the patient in perfect quiet; do not 
give food or anything else. In the intervals many of the 
measures recommended for neuralgia in general are indicated; 
among the most useful are strychnine, arsenic, quinine, and 
bromide of potassium. Tincture of cannabis indica in doses 
from 5 to 10 minims thrice daily has been found beneficial. 
Attend to the state of the alimentary canal; avoid the. causes 
which are likely to give rise to an attack of migraine. 

Delirium Tremens. 

Synonym. — Mania a potu. 

Symptoms. — Sleeplessness, debility, tremors, horror, hallu- 
cinations; often with loss of digestive power. The insomnia 
is a cardinal symptom; if the patient sleeps a whole night he 
recovers. Debility varies in degree in different cases; in a 
first attack it is not always great. Tremor is nearly always 
present. The illusions of the patient are wonderfully real, 
and usually dreadful. He is pursued by demons or beset by 
mortal enemies; he cannot bear to be alone, especially in the 
dark. Sometimes, however, the visions are indifferent, or 
even amusing. The patient may suppose himself to be well, 
and engage about his usual avocation ; going through all its 
movements in pantomime, though with empty hands. 

After several days and nights of sleeplessness, prostration 
usually increases; the skin grows cold and clammy, the voice 
feeble, and the patient no longer inclines to move about. 
Death may result, if sleep be not obtained, within a week, or, 
at the most, two weeks. In favorable cases, a sound sleep of 
many hours comes on within three or four days; the patient 
then wakes up rational and well. 

Causes. — There is no room for doubt that this affection 
may come on under two different conditions or circumstances : 
1, where stimulants are suddenly withdrawn from one 



DELIEIUM TREMENS. 433 

accustomed to them; and 2, while their use in excess is 
continued. The second class furnishes the most dangerous 
cases. 

Treatment. — Old as this disease is, it is yet the subject of 
great difference of opinion. If the patient be not much 
prostrated, give only ale or porter, a bottle or two in the day ; 
with hop tea ad libitum, and a grain of opium every three or 
four hours. The latter may be increased, if sleep be delayed, 
to a grain every two hours; or, as a maximum, a grain every 
hour. Very weak patients, accustomed to spirits, might have 
a tablespoonful of whisky or brandy every four, three, or two 
hours, according to their condition. Hydrate of chloral some- 
times answers as well as, or better than, opium. Beef-tea and 
mutton-broth, etc., seasoned with red pepper, are preferred as 
•diet. In an obstinate case, sleep may follow the raising of a 
blister upon the back of the neck. Substituting valerian for 
opium, or combining the fluid extract or tincture of valerian 
with morphia solution, answers well in some cases. Injection 
■of laudanum into the rectum is occasionally resorted to. 

Other modes of treatment have been urged. 1. The 
expectant treatment, giving only strong food, without stimu- 
lants or opium. 2. The treatment by half-tablespoonful 
doses of tincture of digitalis. 3. That by the internal use of 
chloroform, in one or two drachm doses. 

The digitalis treatment, bold as it seems, has a good deal of 
positive testimony in its favor. Why not try, as some do, 
less immense, and yet large doses; as half a drachm or a 
drachm, instead of half an ounce, of the tincture, every three 
or four hours? 

Many have recently reported excellent success with one or 
two drachm doses of chloroform. The corrugated stomach of 
a spirit drinker will probably bear the pungency of chloro- 
form better than another's. Generally only one or two such 
doses of it are said to be required given in mucilage. 

The large majority of first attacks of mania a potu are 

31* 



434 HYSTEEIA. 

curable. Third and fourth severe attacks are said to be often 
fatal, or are followed by permanent insanity, or idiocy. There 
are exceptions. I have attended patients having had twelve 
to fifteen severe attacks prior to such unfortunate results. 

Hysteria — Functional Nervous Disease. 

From its occurrence nearly always in females, and from a 
supposition of its originating in some affection of the womb, 
this name has been given to a variable disorder, of which the 
main characteristic is, morbid excitability of the whole nervous 
system. 

A "fit of hysterics" is a paroxysm whose nature may vary, 
from mere uncontrollable laughter or crying, to a severe 
epileptiform convulsion. This last, however, differs from 
epilepsy, in there being less complete loss of consciousness,, 
and in its curability. It is often preceded by a sensation 
(globus hystericus) like that of a ball rising towards the 
throat. 

Simulation of other diseases, indeed the assumption of severe 
functional disorders of different organs, is a common trait of 
hysteria. There may be hysterical amaurosis ; hysterical 
insanity is not uncommon; nor is hysterical paraplegia or 
coma rare. Retention of urine, cough, aphonia, etc., are often 
thus produced. 

Pathology and Etiology. — Hysteria is a very complex 
morbid condition, of the nature of which it is impossible to- 
speak definitely. It is a nervous disorder, but its exact seat 
cannot be localized, though probably the brain is most dis- 
turbed. No characteristic pathological change has been 
discovered, but there is probably a nutritive derangement of 
the entire nervous system. The attempt to localize the 
primary disorder in the sympathetic ganglia, and to attribute 
the phenomena observed to vaso-motor disturbance, has no- 
sufficient foundation. 

Hysteria is infinitely more common among females, begin- 



HYSTERIA. 435 

ning usually from 15 to 18 or 20 years of age, but sometimes 
much earlier or later, and rarely only at the change of life. 
Young girls, old maids, widows, and childless married women 
are the most frequent subjects of the complaint, and its 
manifestations often cease after marriage. Fits of hysteria are 
more common about the menstrual periods. It has been 
attributed to malpositions of the uterus, undue sexual excite- 
ment, unsatisfied desire, sexual excess, disordered menstrua- 
tion, as menorrhagia, amenorrhoea, or dysmenorrhea. Many 
eminent authorities deny that these constitute the essence of 
the complaint. Its frequency in women is due to the inherent 
conditions of their nervous system, often aggravated by their 
mode of existence, as disordered by conditions, the sexual 
functions assume an undue prominence in the mind ; thus 
disturbance produces an exaggerated effect. In many cases 
there is nothing wrong about the generative organs or func- 
tions; it occurs often in married women with families. The 
improvement which takes place after marriage may be due to 
the change in habits, thoughts, purposes, occupation, and 
surroundings. 

Hysteria is often due to digestive disturbances, constipation 
with accumulation of faeces. Causes referable to the mode in 
which girls are brought up and their general habits of life aid 
materially in its production, as want of useful occupation, 
indolent and luxurious habits, overpetting and spoiling, sub- 
jection to the worries of fashionable life, keeping late hours at 
parties, reading sentimental novels, etc. Temperament and 
hereditary predisposition to nervous affections may have influ- 
ence; the latter may be explained by the patient imitating a 
hysterical mother. In many cases hysteria results from 
depressing influences, as anxiety, grief, disappointed affection, 
overwork, bad feeling and improper hygienic conditions. It 
may be due to some chronic disease. In instances the con- 
dition can only be attributed to perversity. 

The hysterical state is observed in males, but rarely an 
actual^. The subjects are from 35 to 50 years of age; due 



436 HYSTERIA. 

to excessive venery or masturbation, overwork, worry and 
anxiety, excessive and prolonged mental labor, senile degener- 
ation, or commencing chronic cerebral disease. 

The exciting cause of the first hysterical fit is some sudden 
emotional disturbance; may be slight if the patient has been 
in mental restraint, with pent-up feelings, or subject *to 
depressing influences for a considerable period. Subsequent 
ones arise from less disturbance. Suppressed laughter may 
lead to very severe fits. Occasionally they result from 
physical disturbance, as an injury, loss of blood, or acute 
illness. 

Symptoms. — It is impossible to give even an outline of all 
the varieties of clinical phenomena which rmiy be presented in 
eases of hysteria. There is scarcely a complaint which may 
not be simulated. The prominent features are undue excita- 
bility of the emotions, defect in the power of the will and 
intellect ; alterations in the general cutaneous sensibility and 
•special senses, usually hyperesthesia and dysesthesia; a 
tendency to involuntary muscular movements or other dis- 
turbance of the motor functions. 

Characters of an Hysterical Fit. — As a rule it occurs when 
-other persons are present, and never during sleep; is not 
sudden, gradually worked up, having time to place herself 
in a comfortable position and adjust her dress; often preceded 
by sighing, sobbing, laughing, moaning, nonsensical talking, 
gesticulation, or a feeling of globus hystericus; no peculiar 
cry. During the fit apparent unconsciousness, not complete, 
as can be determined by touching the conjunctiva; patient 
generally knows what is going on, looks out from under her 
eyelids occasionally. Spasmodic movements occur, varying 
from slight twitchings in the limbs to general convulsions o* al- 
most tetanic spasms; patients struggle, throw themselves about; 
thumb is turned in and hand clenched. These movements 
may last a few moments or an indefinite time, with or without 
intermissions; no lividity of the face or sign of interference 
w T ith respiration. Breathing noisy; irregular, gurgling, splut- 



HYSTEEIA. 437 

tering sounds are produced in the throat and mouth. The 
pupils not dilated; slight internal strabismus; the eyes turned 
up from time to time. The pulse normal. No biting of 
tongue, rarely foaming at the mouth. The paroxysm gener- 
ally terminates with crying, laughing ; sighing or yawning, 
and followed by exhaustion, not by coma; in rare instances 
the patient falls into a prolonged trance. Eructations of gas 
and a copious discharge of pale, watery urine may occur. 
Earely is followed by a state of hysterical mania, the patient 
not responsible for her actions. 

Certain nervous phenomena are : 1 . Catalepsy, the will cut 
off from certain muscles, and whatever position the affected 
part, as a limb, is placed, it remains fixed an indefinite time. 
It may or not be accompanied with unconsciousness. Sensa- 
tion usually much impaired, and may be lost. This is some-, 
times associated with organie disease of the brain, or severe 
organic visceral disease. 2. Trance. The individual lies as 
if dead, ghastly pale, circulation and respiration almost 
ceased. Such have been "laid out" as dead. 3. Ecstasy, in 
which visions are seen. Often this is combined with ridicu- 
lous dancing movements, as with certain religious com- 
munities. 

Diagnosis. — Attention to tho characters described, and the 
circumstances under which it arises, will enable it to be dis- 
tinguished from all other "fits." In women, hysteria affords 
an explanation of many of the ailments of which they com- 
plain. Among the important affections which it may simulate 
are diseases of the brain and spinal cord; disease of the spinal 
column; peritonitis; abdominal tumors; laryngitis; and diseases 
of joints. The general signs of hysteria; absence of pyrexia, 
or of characteristic symptoms belonging to the several affec- 
tions; peculiar superficial nature of any pain or tenderness; 
characters of the different kinds of paralysis, as described ; 
and use of chloroform, will generally enable a satisfactory 
conclusion. 



438 HYSTERIA. 

Treatment. — 1. Of a Hysterical Fit. — Little interference 
is needed. Important matter is to get rid of the officious, 
sympathizing individuals who surround the patient. She 
should be treated firmly, but kindly; gain her confidence, first 
ascertaining, if possible, the cause of the fit. Care to avoid 
injury, and the clothes should be loosened. If anything 
further is needed, affusion of cold water, ammonia to the 
nostrils, or closing firmly the nostrils and mouth for an 
instant, so that the patient cannot breathe. In obstinate 
€ases a moderate galvanic shock. If medicine is needed, 
spirits of ammonia with valerian or assafoetida. 

2. During the Intervals. — The treatment of persistent and 
marked hysteria is often very difficult. Mental and moral 
guidance is important; the patient should be taught to look 
away from herself and her grievances, and to engage in some 
useful occupation. Any wrong habit must be rectified. 
Change of scene and associations, with traveling. Any cause 
of discomfort at home or elsewhere should be removed. 
General treatment of the state of the system and blood, atten- 
tion to diet and the digestive organs. Avoid alcoholic, 
stimulants. Various symptoms call for interference. Pains 
in different parts are relieved by belladonna or opium 
plasters, or anodyne liniments; in the joints by warm poultices 
or fomentations with laudanum sprinkled on. Hypodermic 
injection of morphia may be required. For restlessness and 
sleeplessness bromide of potassium is the best. Paralysis 
must be treated by electricity, and rigidity counteracted by 
fixing the limbs in other positions by splints or other 
mechanical apparatus, and by movements. If necessary, 
chloroform may be used. This may be employed to remove 
"phantom tumor." I have cured aphonia by a small blister 
across the larynx, or even a small belladonna plaster, these 
probably acting through the mind. The vocal cords may be 
galvanized, or the patient charged with electricity, and sparks 
taken from over the larynx. It is questionable how far such 
drugs as assafoetida, valerian, etc., are useful in hysteria, when 



HYPOCHONDRIASIS. 439 

used as a means of cure, except in that they are very disagree- 
able; they are valuable as antispasmodics. 

Hypochondriasis. 

This affection is merely a mental condition characterized by 
inordinate attention on the part of the patient to his own real 
or supposed bodily ailments and sensations. Adult males who 
have no occupation are the usual subjects, but it is common 
among workingmen. As a rule, there has been some disease, 
digestive or biliary disorders, venereal disease, or acute illness. 
In other instances the symptoms are quite imaginary. The 
sensations complained of vary much, and are liable to be 
changed or new symptoms added, for which the hypochondriac 
is on the lookout. These patients generally present a healthy 
appearance, and sleep and perform their ordinary functions 
satisfactorily. They go the round of the "doctors," take any 
amount of physic, which they want to be always changing, 
particularly trying any new remedy that comes up; are 
delighted to talk about their ailments, often making use of 
scientific terms; consult every medical work they can; are 
much addicted to examining their pulse, tongue, urine, and 
stools. They are very particular about their food and drink, 
and often as to their dress and general "get-up." Hydro- 
pathic and similar places famed for mineral waters are 
favorite resorts for hypochondriacs. The moral character and 
feelings towards friends are unaltered. These cases are 
always very difficult to improve, and frequently quite incura- 
ble. Ultimately they may become wretched misanthropes, 
and shut themselves up or away from all society. 

Treatment. — The main thing in treating hypochondriasis 
is, to try to get some control over them, and to make them 
believe in you, by investigating their case properly, and show- 
ing that you thoroughly understand it. They cannot be 
talked out of their ailments, but kind argument may often do 
much, and they should be urged to take their attention off 
themselves, and mingle in society, travel, or otherwise occup 



440 DISEASES OF THE SKIN. 

their time. Attention must be paid to bathing, exercise, and 
other modes of maintaining the health. The diet and state of 
the digestive organs should be regulated. Something has 
generally to be given, and the best is to treat the prominent 
symptoms, taking care not to give anything that can do harm. 
It is often useful to send hypochondriacs to hydropathic 
institutions or mineral spas, chiefly on account of the change 
of experience, and society. 



CHAPTER XII. 

DISEASES OF THE SKIN. 

The term "skin disease" applies to every deviation from the 1 
normal condition of the structure and function of the skin and 
its appendages, the glands, hairs, and nails. The so-called 
surgical diseases of the skin will be omitted and remarks 
confined to those affections which come under the care of the 
physician. 

But in order to study diseases of the skin profitably, we 
must at the outset adopt some method of classification,, 
whereby we may arrange into groups and classes the various; 
affections which bear some relation to one another. The best 
method, perhaps, would be an anatomico-pathological one, the 
different diseases being divided into two great classes, namely^ 
those having a constitutional origin and those purely local. 
Unfortunately, this is, in the present state of our knowledge, 
impossible. 

Many skin affections are clearly constitutional and many 
purely local; there is an intermediate class which may be local 
or constitutional, or even partake of the characters of both. 
For instance, some diseases which are purely local may be- 
aggravated or determined by constitutional conditions, while 
many affections, due really to some morbid condition of the- 



EXANTHEMATOUS INFLAMMATION. 441 

general system, are determined by some cause acting locally. 
A strict anatomico-pathological classification would become 
too complicated by the never-ending extensions and modifica- 
tions of morbid processes. 

The best adapted arrangement for clinical study and the 
most useful in assisting students in preparing for examina- 
tions is : 

1. The Eruptions of the Acute Specific Diseases. — These have 
already been described. 

2. Local Inflammations, including: Erythematous, as ery- 
thema, roseola, and urticaria. Catarrhal, as eczema. Bullous, 
as herpes, pemphigus. Suppurative, as ecthyma, impetigo, 
impetigo contagiosa, and furunculus. Plastic, as lichen and 
prurigo. Squamous, as psoriasis, pityriasis, simplex, and 
pityriasis rubra. 

3. Diathetic affections, including strumous, syphilitic, and 
leprous. 

4. Hypertrophic and Atrophic, under which may be classed 
xeroderma and ichthyosis, keloid, fibroma, scleroderma, as 
hypertrophies; and atrophy and senile decay, as atrophies. 

5. New formations, as lupus, rodent ulcer, and cancer. 

6. Hemorrhages, as purpura. 

7. Neuroses, as hyperesthesia, anaesthesia, and pruritus. 

8. Pigmentary changes. 

9. Parasitic Diseases. — Dermatozoic, as scabies, phtheiriasis. 
Dermatophyte, as tinea favosa, tinea tonsurans, tinea kerion, 
tinea circinata, tinea sycosis, tinea versicolor, onychomycosis, 
and, according to some, tinea decalvans. 

10. Diseases of Glands and Appendages. — Sweat glands, as 
miliaria, sudamina, and lichen tropicus, etc. Sebaceous glands, 
seborrhoea, acne, xanthelasma, molluscum contagiosum. Haws 
and their follicles. Nails. 

EXANTHEMATOUS INFLAMMATION. 

In this there is active congestion or hyperemia of the "der- 
ma" or true skin. Besides scarlatina, measles, and erysipelas, 



442 EXANTHEMATOUS INFLAMMATION. 

already considered, this order contains erythema, urticaria, and 
roseola. 

Erythema. — Superficial, circumscribed red patches, of 
variable shape and size, on the face, trunk, or limbs, not pain- 
ful nor very sore, characterize this. Its causes are, all moder- 
atebut somewhat continued irritants to the skin. Its duration 
is generally but for a few days or a week or two. No fever 
attends it ; nor is it either contagious or dangerous. 

Varieties* of erythema are, erythema fugax, or fleeting ; 
erythema intertrigo, from friction of two surfaces of the skin, as 
in not well-cleaned children ; erythema rheumatica, occurring 
now and then in rheumatic fever; erythema pernio, or 
unabraded chilblain ; and erythema nodosum, on the legs, with 
rounded node-like prominent red patches, somewhat more in- 
flamed than in the other forms. 

Treatment of erythema must depend upon its cause more 
than upon its particular form. The stomach and bowels may 
need attention, with the use of antacids and laxatives ; 
especially magnesia and rhubarb, or Eochelle salts, or the 
citrate of magnesium. 

Local applications may be, finely-powdered starch or arrow- 
root, dusted on dry; cold cream (unguent, aq. ros.) ; lime-water 
and oil, equal parts (olive, or lard oil) ; ointment or glycerite 
of zinc ; glycero-cerate of lead ; or glyceramyl. 

For erythema pernio or frost-bite of mild degree, astringents 
are serviceable ; as bathing the feet in tepid infusion or decoc- 
tion of oak bark, or solution of alum ; or applying cerate or 
glycerite of carbonate or nitrate of lead. Some recommend 
cabbage leaves. 

Urticaria, Nettle-rash. — Elevated round or oval, red or 
white patches or wheals characterize this. They may come 
and go in an hour, over the arms, trunk, or legs. Much 
burning, stinging, or itching attends them. The affection 

*Here, as in other affections of the skin, only the principal varieties are 
named. Wilson makes sixteen varieties of erythema. 



PAPULAE. 443 

oommonly lasts only a week or two ; sometimes it is chronic 
and tedious. 

Disorder of the stomach from unwholesome food is rather 
more likely to cause nettle-rash than any other kind of 
eruption. Mild purgatives, especially salines or the antacid 
magnesia, with or without powdered charcoal, are suitable for 
it, after a dose (two or three grains) of leptandrin Light diet 
is necessary. Vinegar and water, glycerine and rose-water, or 
the starch-powder, etc., mentioned for erythema, will answer 
for local applications. Much use of cold lotions should be 
avoided, lest the eruption be over-hastily repelled, inducing 
gastric, hepatic, or other internal disturbance. 

Roseola. — Bright, and yet generally dark red, damask rose- 
colored patches, irregular in shape and of various size, over 
any part of the body, without much if any fever, belong to this 
affection. It is generally of but a few days' duration. Some- 
times a certain amount of resemblance is presented by it to 
scarlet fever or measles ; but the peculiar sore-throat of the 
former, and the catarrhal symptoms of the latter, are wantin 

Scarcely any treatment is called for in roseola ; no local 
application, as the rash is but slightly irritating ; and only 
such medicines as the general condition of the patient may 
indicate. 

Papula. 

These, pimply eruptions, involve depositive inflammation of 
the skin, which is raised in small, red, round, or conical points 
or minute tubercles, not very hard, and often, though not 
always, transitory. Papular affections are Lichen and 
Strophulus. 

Lichen. — Pimples numerous, but of small size j red, and 
more or less heated and irritated. The principal forms of it 
are lichen simplex, common on the face, neck, etc., lichen trop- 
icus, or prickly heat, and lichen agrius. The last named is the 
most inflamed and painful; sometimes quite severe. Lichen 
simplex, though mild, may be obstinate in its persistence; 



444 papula. 

annoying ladies, sometimes, by remaining long on the face. 
In lichen tropicus, from which children, especially, often 
suffer in summer time, the eruption is not prominent, but the 
sense of irritation is very unpleasant. 

Lichen agrius may become, in violent or neglected cases, a 
scabby confluent eruption, with cracks or fissures, and a serous, 
perhaps purulent, discharge. This is not, however, veiy 
common. 

Treatment. — Even for the simple form, and still more for 
lichen agrius, constitutional alteratives are likely to bo 
needed, doing more good than local applications. In lichen 
tropicus, starch-powder, glycerine and rose-water, or glycer- 
amyl, or weak lead-water will suffice, without any medicine. 
But in the other forms, rectification of any error of balance in 
the system must first be made. The plethoric must have low 
diet ; the ansemic, lean meat, perhaps bitters, aromatic sul- 
phuric, or nitric acid, or iron. Costiveness must be over- 
come, as by cream of tartar and sulphur, rhubarb and aloes, 
or other mild but decided laxatives. Then arsenic may be 
prescribed ; of Fowler's liq. potass, arsenit., three drops twice 
daily at first, increased every week one drop until ten twice 
daily have been taken ; omitting the remedy if headache^ 
nausea, diarrhoea, or puffiness of the face occur. 

In lichen agrius, rest in bed may be required ; with lime- 
water and oil dressing, or poultices of bread and milk, or 
flaxseed meal, or slippery elm bark powder, glyceramyl, etc. 

Strophulus — Red gum is a common name for this papular 
eruption of infancy. Indigestion, reflex irritation from deten- 
tition and over-thick clothing, or living in hot rooms, may 
produce it. The eruption is not severe, consisting of many 
small red pimples, close together, and often nearly all over- 
the body. Attention to the stomach and bowels is necessary, 
Lancing the gums is proper if they be swollen, tender, or so- 
tense as evidently to distress the child. To the rash, only 
very soothing applications should be made, as starch-powder,, 
ointment of oxide of zinc, or glyceramyl. Care with the diet,, 



VESICULJ3. 445 

If fed instead of being nursed, is of great importance some- 
times. 

Vesicul^e. 

These are effusive inflammations of the derma ; characterized 
by numerous and small water blisters ; the smallest are sudam- 
ina; the largest, herpes; eczema having vesicles of intermediate 
size, and scattered. Sudamina are met with in low fevers, 
consumption, etc., mostly when perspiration alternates with 
the febrile state in an enfeebled system. 

Eczema. — This has been the subject of much disputation ; as 
to whether it is a disease per se, going through stages not only 
of effusion, but also of incrustation, suppuration, desquama- 
tion, etc., ; or, only a phase of cutaneous irritation and 
inflammation, called vesicular, whatever its cause, and eczema- 
tous to distinguish it from the hepatic eruptions. Unable to 
decide this question with positiveness, we may say, merely, 
that, while the eczematous vesicular eruption admits of very 
distinct description and recognition^ it may come from or after 
a papular rash, and may in the same case be transformed (or 
progress) into a pustular or scabbing disease. 

Eczema simplex, rubrum, infantile, and impetiginodes are its 
principal varieties. Besides others named in the books, there 
are also eczema solare, from heat, and eczema mtrcurialis, from 
the impression of mercury on the system. The simple form 
has but little inflammation ; but there is always some soreness 
and the vesicles may run together and break, oozing serum or 
lymph, or scabbing lightly. Eczema rubrum is more inflamed 
with redness, heat, and some tumefaction. Crusta lactea, or 
milk crust, is a name often given to eczema infantile of the 
nursing time. It affects the face, sometimes very unpleasantly ; 
scabbing, running, and cracking all over it. E. impetiginodes 
appears to be an intermediate stage, or transition, between 
eczema and impetigo ; water blisters appearing at first, and 
pustules afterward. 

Treatment. — An inflammatory state attends the eczema- 



446 VESICULJE. 

tous eruption, nearly always ; especially in eczema rubrum and 
advanced crusta lactea. Saline laxatives, diuretics and dia- 
phoretics (Rochelle salts, bitartrate of potassium, citrate of 
potassium, etc.) are often called for, perhaps to be repeated in 
moderate doses. Light diet is, in like case, proper. In 
children, small doses of podophyllin occasionally do good. 
Locally, weak lead- water when there is no scabbing ; lime- 
water and oil when there is great irritation ; decoction of 
bran ; flaxseed infusion with bicarbonate of sodium (3j in 
f§iv) ; glyceramyl ; glycerine with rose-water ; carbonate of 
lead cerate ; ointment of oxide of zinc ; these are among the 
many applications used with advantage. The whole bath, 
tepid or slightly warm (never hot) two or three times a week, 
will be beneficial. In chronic eczema, the " Turkish" or dry, 
hot air bath (130° to 150°) is highly recommended by some. 

Chronic eczema requires alterative treatment internally. 
Arsenic is the alterative in obstinate cutaneous affections. Its 
peculiar action on the skin tends to displace the morbid 
process, and thus to restore, after its own transient influence is 
withdrawn, healthy nutrition and reparation. Five drops of 
Fowler's solution may be given at first, twice daily, increased 
gradually until the dose amounts to ten drops ; sometimes 
even more. The medicine must be intermitted, if the head, 
stomach or bowels show its decided action. In case of its 
failure, particularly where syphilitic taint is possible, Dono- 
van's solution may be given ; three drops at first, cautiously 
increased. Scrofulous or otherwise feeble children may need 
cod-liver oil. In crusta lactea, or eczema infantile, the mother 
or nurse must be instructed not to burden the child with 
clothes, nor keep it in an overheated room. Daily bathing is 
particularly important to an infant suffering with such an 
eruption. 

Herpes. — This has larger, more separated and less numerous 
vesicles than eczema ; it is less apt to be chronic. Varieties : 
herpes phlyctenodes, herpes zoster, and herpes circinatus. The 
first is the most frequent ; receiving also local names, accord- 



BULLAE. 447 

ing to its seat ; as h. labialis prceputialis, etc. Herpes labialis 
is commonly called " fever blisters." 

Herpes zoster is singular, and not very common. Half of 
the body, about the waist, is covered with vesicles, on an 
inflamed red surface. Sometimes neuralgic pains, quite 
severe, attend it. It generally aifects the right side. Its 
duration is but for a week or two; unless in the feeble or old, 
in which it may be followed by ulcerations of a tedious, 
perhaps dangerous character. 

Herpes circinatus is distributed in circular patches or rings. 
Minute vesicles appear around the circumference. By these, 
and the absence of the microscopic vegetation, and by less 
disposition to chronicity, it is distinguished from tinea tonsur- 
ans, or true contagious ringworm. Herpes iris, of writers, is 
an aborted h. circinatus; the rings being incomplete. 

Herpes rarely appears in old persons; often in children and 
adolescents. All causes of irritation of the surface of the 
body may produce it; as febrile or catarrhal attacks, stimulat- 
ing diet, violent exercise, etc. 

For the treatment of herpes, the plan stated for eczema is, 
principle, here also suitable. Cucumber ointment may be 
added to the applications recommended. Herpes zoster 
requires confinement to bed. The severe pains, in this, may 
call for anodynes. Herpes labialis is sometimes very annoy- 
ing, especially to ladies. Pure cologne-water, applied at the 
very start, may abort the vesicles. Magnesia powder is used 
by some to dust about the lips. Calomel ointment is recom- 
mended when the eruption is chronic, coming out in successive 
crops. Oxide of zinc powder is often good. 

Bullae. 

These are eruptions of large vesicles. Pemphigus and 
JRupia are the most distinct. 

Pemphigus.— Bull se of a circular or oval shape,, from half an 
inch to two inches in diameter, and flattened. They may be 
distributed over any or all parts of the body. Fever, some- 



448 pustule. 

times considerable, precedes and accompanies the eruption. 
After the vesicles mature, they burst, or dry away, leaving 
thin brown scabs. Ulceration may occur, but it is not deep 
or obstinate, unless in a particularly unhealthy constitution. 
The duration of pemphigus is from one to three weeks, or 
more in bad cases. Pompholyx is the name given to a rare 
variety of pemphigus, in which the space continuously covered 
by bullae is large, and there is little or no fever. A fly-blister 
causes artificial pompholyx. 

Pemphigus is not usually considered to be contagious. One 
family came under my notice, however, in which five individ- 
uals were attacked by it, partly in succession, after traveling. 
It was difficult in that case not to suppose contagion. 

In the treatment of pemphigus, gentle refrigerant laxa- 
tives at first, diuretics and diaphoretics next, and, often quite 
early, tonics and supporting regimen, are called for. No 
local applications, other than the mildest lotions or unguents, 
will be suitable. The early puncture of each bulla with a 
small needle is recommended; but the raised cuticle must not 
be removed. 

Rupia is probably but a modification of pemphigus ; with 
smaller blebs or bullae, followed by thicker conical scabs of 
dark color ; after whose removal ulcers are left, which may be 
weeks in healing. Rupia simplex is the variety in which the 
scabs are low and the ulcers slight ; rupia prominens in which 
they are elevated into irregular cones ; rupia escharotica, when 
the ulceration is deep and extended. Syphilitic rupia is quite 
common ; but every case of rupia is not, by authorities, 
admitted to be syphilitic. Observation goes to sustain this 
non-admission. 

Treatment of rupia requires to be, generally, tonic and 
Iterative. Quinine, cod-liver oil, and iodide of potassium, 
with good but simple diet, are apt to be wante d for it, 

Pustules. 

Suppurative inflammation of the skin (excluding smallpox. 



PUSTULJG. 449 

furuncle, and carbuncle, as well as the malignant pustule or 
charbon of the French, a rare affection said to be received 
from cattle) appears in the two forms, Ecthyma and Impetigo. 

Ecthyma. — Large, round, prominent pustules, upon any 
part of the body, not numerous ; ending in thick dark scabs 
followed by slight (or in cachectic states, obstinate) ulcera- 
tions. Ointment of tartar emetic, or pure croton oil, or other 
strong cutaneous irritants, will produce it. Often, however, 
especially in syphilitic persons, or after acute fevers, etc., it 
occurs without local exciting cause. Sometimes it is chronic. 

" In treatment the causation is of great importance. If a 
local irritant produces it, local emollients, perhaps with 
general refrigerants, are to be used for its relief. Otherwise, 
diet, and balancive measures will be more in place; tonics for 
the feeble, purgatives and light regimen for the plethoric, etc. 

Arsenic is called for in obstinate cases, as in other diseases 
of the skin; Fowler's or Donovan's solution, in small doses 
carefully increased. 

Impetigo. — Small and somewhat numerous pustules : varie- 
ties, impetigo figurata and impetigo sparsa. I. figurata is most 
common on the face, in circumscribed clusters of pustules, 
which may become confluent and scab. To this, in children, 
as well as to eczema infantile, the name of crusta lactea is given 
by authors. II. sparsa has the pustules scattered ovei more or 
less of the whole body. 

Treatment. — When much irritation or inflammation exists, 
lead-water, glyceramyl, ointment of oxide of zinc, lime-water 
and olive oil, flaxseed tea and bicarbonate of sodium, light 
poultices of flaxseed meal, slippery elm bark, or bread crumb, 
are to be applied. Daily use of castile soap and water is 
serviceable. Purgatives may be needed. Diet must be 
according to the general condition of the patient. Impetigo 
may affect the hairy scalp; if so, the hair must be cut and kept 



450 SQUAMA. 

very short. Colchicum and ipecac may be given in acute 
cases; arsenic in those which become chronic. 

Squamjs. 

Scaly diseases are. Lepra {Alphas of Wilson), Psoriasis, 
Leprosy of the Hebrews, Spedalsked, or Norwegian leprosy, 
Pityriasis, and Ichthyosis. 

Lepra. — Always chronic, and very difficult to cure. Not 
regarded as contagious, though it has been seen to occur suc- 
cessively in four persons in immediate contact (an infant at 
the breast, its wet-nurse, another infant suckled by her, and 
her husband). It is characterized by red desquamating 
patches, of various sizes, approximating to a circular shape, on 
any parts of the body ; especially on the arms and legs. Be- 
sides syphilitic lepra, its varieties are lepra vulgaris, with 
small patches and few thin scales, and lepra inveterata (alphos 
diffusus of Wilson) where they are large and desquamate 
extensively. 

In both, the margin of the patch is the highest, reddest, and 
most squamous part. 

Psoriasis. — Described under the names of ps. vulgaris, 
gyrata, and inveterata, psoriasis differs mainly from lepra in 
the irregular and varied forms of the desquamating patches ; 
and in the absence or less degree of depression near their 
centres. Wilson's view, that psoriasis is only a kind of 
chronic eczema, does not seem to accord with the facts of its 
ordinary history. It is sometimes hereditary ; as also lepra. 
No disease of the skin is so hard to eradicate, unless it be 
ichthyosis. 

Treatment. — For lepra and psoriasis alike, all sorts of 
alterative agencies, local and systemic, are, if cautiously used, 
suitable for tentative practice. Our object is to obtain the 
making of a new skin, unaffected by the morbid habitude of 
nutrition. Frequent bathing should be practiced. Tar oint- 
ment, ointment of sulphuret of potassium, etc., may be applied. 



SQUAMJE. 45 . 

Arsenic, and the iodide of arsenic given carefully, but repeat- 
edly, through long periods. Other medication must depend 
upon the conditions of each case. 

Ichthyosis (Fish-skin disease). — This is rare. Hard, thick, 
dry scales form, continuously, over a part, or, sometimes, 
nearly the whole surface of the body ; without much redness, 
soreness, or even itching. It is congenital and incurable. 
Frequent and thorough ablutions, and mild emollient applica- 
tions, are palliative to it. 

Pityriasis. — This is a chronic affection in which very 
numerous small white scales (dandruff) form upon the skin, 
particularly the scalp (p. capitis). Some redness, and often a 
good deal of itching, may attend it. It is difficult of cure in 
many cases. If it be upon the head, keeping the hair short, 
and washing daily with castile soap, followed by a spiritous 
lotion, or glycerine and rosewater, will do the best for it. 
Cleanliness and frequent bathing in tepid, cool, or, if the 
vigor of the system permit, cold water, are of essential import- 
ance in all cases. 

The term pityriasis versicolor is sometimes applied to an 
epiphytic disease, one connected with a vegetable parasitic 
growth, better called chloasma versicolor. 

Spedalshed is a disorder only known in Norway and 
Sweden, especially among the fisherman. Accounts of it are 
given in medical journals and books; but the mere mention of 
It will suffice here. (See Elephantiasis Grcecorum.) 

Leprosy of the Bible (Lepra Hebrseorum) is of great his- 
torical interest. It is still recognizable in the East, though 
not frequently met with. 

In the Book of Leviticus, three varieties of leprosy are 
described : dull or darkish white " freckled spots " — dusky or 
shadowed — and bright white (bahereth lebhana), the worst of 
all. Tsorat (whence psora, and sore) or malignant disease, 
was applied to the last two only. Lepra is an early Greek 
synonym of this term. 



452 MACULE. 

Mason Good thus describes the old leprosy : "A glossy ^ 
white, and spreading scale upon an elevated base ; the eleva- 
tion depressed into the middle, but without change of color ; 
the black hair on the patches, which is of the natural color of 
the hair in Palestine, participating in the whiteness, and the 
patches themselves perpetually widening their outline." 

In favorable cases, after spreading over much of the person,, 
though without ulceration, the disease would die out; the 
scales would dry up and gradually disappear. In bad case& 
ulceration would occur, with extensive sores, as well as- 
desquamation. Then the leper was made an outcast, and 
treated as one dead : " unclean for life." 

Not only the Books of Moses, and others of the Bible, but 
also Hippocrates, Galen, and Celsus speak of ancient leprosy 
as a white scaly disease. It thus differs decidedly from any 
kind of elephantiasis. 

Macule. 

Ephelis, Vitiligo and Chloasma may be included under this 
term ; perhaps better, under, that of Decolor ationes. 

JEphelis; Lentigo. — Sunburn and freckles best correspond 
with these names ; which, however, are by some authors ex- 
tended further. Neither are of importance unless in regard 
to appearance. For the removal of freckles (which often dis- 
appear spontaneously with time) or the yellowish-brown spots- 
called chloasma, or melasma, all applications may fail ; dilute 
nitro-muriatic acid (fifteen to thirty drops in an ounce), left 
for some time in contact with the discolored spot, is more 
likely than anything else to take effect. Nitrate of potassium,, 
in saturated solution, is asserted to remove freckles after a few 
applications. 

Vitiligo. — Literally, veal-skin. Unnatural whiteness from 
deficiency of coloring matter. When universal over the body 
(nearly always then congenital) it is albinismus. We see 
albinoes, sometimes families of them, occasionally, in all the 



HYPERTROPHIC 453 

Taces of mankind/ as well as among the lower animals. 
Leucoderma, white skin, and Leucopathia, or white disease, 
are names given by some writers to the affection. 

When local, vitiligo is seen mostly in rounded patches or 
spots, which slowly increase in size, though without regular- 
ity of shape. The head, chest, back, and thighs are the most 
frequent seat of them. The hairs on the parts involved 
become white, or fall out, causing baldness — calvities, or 
alopecia. 

Treatment for vitiligo must be, first, general, for im- 
provement of nutrition in the whole system — and then local. 
Very hard it may be to cure the affection, although its im- 
portance is chiefly for appearance ; no danger attends it. 
Tannic acid and oil of turpentine are the preferred local 
applications for it. Total albinismus is quite incurable. 

Chloasma (pityriasis) versicolor will be spoken of under 
Parasitica?. 

For alopecia, baldness, or premature loss of the hair, many 
remedies are in vogue. Shaving the hair repeatedly (after an 
illness) may often save the hair. Stimulating applications, 
such as tincture of cantharides, ammonia, etc., sometimes help 
and sometimes hurt the case. Improve the general health 
and invigorate the scalp. 

Hypertrophic. 

Morbid excesses of development of the skin or tissues con- 
nected with it are thus named: Nsevus, Clavus, Verruca, 
Elephantiasis Arabum. 

Ncevus. (Mole, mother-mark.) — This is always congenital. 
Discoloration and elevation of the part exist, with abnormal 
development of the capillaries and small veins of the skin; 
making a small, commonly flat, vascular enlargement. It is 
seldom more than an inch in diameter. Erectility sometimes 
belongs to the vessels of naevus. I have seen it much larger 
and elevated an inch or more. In such cases I use caustic 
alternated with poultices. If large and elevated, caustic 



454 HYPERTROPHIC. 

alternated with poultices, the ligature, the knife, and vaccina- 
tion of the part, have all been employed for the removal of 
such formations. They may leave scars worse than the mole 
if small; the operation ought to be exceptional. The first is 
usually the best treatment. 

Verruca. Wart — A hypertrophy of the skin, with great 
development of the cuticle, especially upon a small surface ; 
such is a wart, of which no one needs a further description. 
Some persons and families are especially liable to them ; why, 
cannot be explained. 

Treatment. — Strong nitric acid ; chromic acid ; caustic 
potassa ; and in slight cases nitrate of silver, carefully applied 
only to the wart, after paring off nearly all the insensitive 
portion of it, will always, at least after repetitions, remove 
warts, also ligation. 

Clavus. Corn. — Most persons are well acquainted with this 
sort of localized hypertrophy of the skin of the foot, from 
irritating friction and intermittent pressure. Prevention is 
more easy, by far, than cure. Corns are either hard or soft ; 
the latter may become inflamed ; the former hurt only under 
decided pressure. 

Pare a hard corn with a sharp knife or razor, closely, but 
not so as to hurt or draw blood. Soak the foot then in warm 
water for thirty minutes, and pick out carefully the center or 
" core." Two or three thicknesses of adhesive plaster, with 
the center cut out (making a ring) should be put over the 
corn ; and another piece, the center not cut out, may be placed 
upon it and them. 

Soft and inflamed corns require removal of all pressure for 
a while, and poulticing, etc., first; then the above treatment. 

Condylomata. — These are fleshy tumors or outgrowths, 
more or less hard and wart-like sometimes, in other cases soft; 
of syphilitic origin often, but not always. They are especially 
apt to occur about the anus, prepuce, and vulva. 

To remove such formations, if they be small and hard, 
nitric acid, pure, may be used, with care to limit its contact to 



TUBEECULA. 455 

the part to be destroyed. "When large and soft, if trouble- 
some enough to require destruction, the ligature is generally 
preferred. It may be, with a needle, passed through the 
centre of the mass, and then drawn and tied tightly about the 
base. 

Elephantiasis Arabum. — Bucnemia Tropica of "Wilson; "Bar- 
badoes Leg." 

Enormous enlargement of the leg, scrotum, or neck, most 
often met with in warm countries, but occasionally anywhere, 
is thus called. The parts become at last hard and nearly im- 
movable. The connective tissue as well as the dermoid 
texture proper is greatly hypertrophied. Impediment to the 
return of surplus material of nutrition by the lymphatics is 
the probable pathogenetic cause ; the nature of this impedi- 
ment has seldom been discerned. 

Ligature of a large artery is asserted to have arrested the 
growth of elephantiasis. No other treatment appears to be 
equally successful in treatment for it. 

TuBERCULA. . 

Acne, Molluscum, Lupus, Elephantiasis Grwcormn, Fram- 
bo&sia, Keloid. 

Acne. — Tuberculous elevations, from inflammation of the 
skin around sebaceous follicles, in which the secretion is de- 
tained, or is of a morbid character, are called acne. Three 
varieties may include all those named by authors : viz., 
acne simplex, acne pustulosa, and acne rosacea. 

Acne simplex or punctata has small and moderately red,, 
rather hard tubercles, on the face principally. When very 
hard and chronic, it may be called acne indurata. Black 
points commonly mark the obstructed follicles. Acne pus- 
tulosa reaches a more mature suppuration, and is often painful, 
especially if upon the scalp. 

Acne rosacea always affects the face ; usually in adults, and 
most often in high livers. A good deal of soreness attends 



456 TUBEECULA. 

the eruption. Firsts the pimples are hard, red, and small ; as 
they mature they grow somewhat larger; finally a little 
sanguinolent pus escapes, leaving a small scab. Rose redness 
around the pimples, or patches of them, has given rise to the 
name. It is generally a dffiicult disease to cure, and very un- 
sightly. Not unfrequently it is hereditary. 

Treatment. — Errors of digestion, brought on by gluttony 
or intemperance, or more moderate imprudence, often cause 
acne. They must be rectified for its cure, Attention to the 
state of the bowels, and to the action of the skin generally, is 
indispensable. Saline cathartics are useful in plethoric cases. 
Various mineral waters are recommended — saline and sul- 
phurous especially. The pustules, when they mature, should 
be carefully punctured with a needle, avoiding irritating dis- 
turbances. Solution of carbonate or bicarbonate of sodium 
(3j in Oj) in water or flaxseed infusion, will be a good wash. 
Sulphuret of potassium, in dilute lotion or ointment, is also 
advised ; or ointment or glycerole of nitrate or amide of mer- 
cury (hydrarg. ammoniat). 

Obstinate cases justify more decided alterative treatment ; 
as the application, by a cotton tip upon a knitting needle, of a 
solution of corrosive sublimate, two to five grains to the 
ounce of water or alcohol, washing it off in a few moments ; 
or, similarly, of pure Goulard's extract (liq. subacetat.) of 
lead, followed by spermaceti ointment, cold cream, or glycer- 
ine and rose-water. Iodide of sulphur ointment, gr. xv to 
xxx in 5j of lard, is also much praised. In acne indurata, 
when very ugly, acid nitrate of mercury (mercury and nitric 
acid each an ounce) has been applied, and sometimes the face 
has been blistered with cantharidal collodion. 

MoUuscum. — Acute molluscum is a somewhat contagious 
tuberculous eruption. The small tumors form without in- 
flammation, increasing slowly, till they have almost the size 
and form of a currant, but without color, and nearly flat- 
based or sessile. They last from three to six months, either 
ulcerating finally and then shrinking away, or inflaming and 



TUBERCULA. 457 

sloughing off, leaving a pit or mark. Several crops of tuber- 
cles may succeed each other on the face and^neck, in either 
adults or children, but especially in the latter. 

Chronic molluscum is of still longer duration; it is not 
contagious, and the tumors are pedunculated, that is, each has 
a stem, in many cases at least ; they also become larger, and 
occur over different parts of the body. Neither form of 
molluscum is common. It is proper to add that some authori- 
ties do not admit the contagiousness of the acute variety. 

Treatment of acute molluscum seems not to be to any 
great extent available. In chronic molluscum the tumors may 
be cut off at the peduncle, the divided point being then 
touched with lunar caustic. 

Lupus. — L. exedens and non-exedens, or 1, superficialis, 
serpiginosus, and devorans [Neligan]. Lupus superficialis is a 
rare disease, in which, most often on the cheek, a small, soft, 
sore, slow-gathering tubercle appears, which in time scabs, 
and ulcerates superficially, the scab and ulcer spreading for 
an indefinite time, and leaving behind them a permanent 
whitish seam or scar. Irritation may make the tubercle very 
painful, and deepen the ulcer. It may last for years. 

Lupus serpiginosus exhibits one or more livid, red, indolent 
tumors on the face, head, or elsewhere, sore, heated, and itch- 
ing. In the course of months they become filled with pus, 
and suffer an undermining ulceration, which finally becomes 
an open, unhealthy-looking sore, forming upon it a hard, 
brown scab. Creeping from the edge of its original seat, in 
irregular rings, the disease extends, leaving behind it a 
depressed cicatrix. The same part may be again reached by 
its meandering progress. This is a very chronic affection, 
even of years' duration, without injuring the general health. 
Lupus exedens or devorans, noli me tangere or rodent ulcer, 
is characterized by continuous destructive ulceration of the 
skin, subcutaneous connective tissue, muscles, and other 
parts, at length involving even bones ; all following tubercles 
" rounded and dusky red," on the nose, cheek, eyelid, etc. An 



458 TUBERCULA. 

ichorous discharge belongs to it; cicatrization follows it r 
sometimes, as in the previous form, to be again attacked. 

Young persons, from ten to thirty, are especially liable to 
lupus. Its progress is generally an affair of years, and it 
causes less suffering thati its appearance would lead us to expect. 
Scrofula certainly and probably syphilis predispose to it. It 
is very difficult to cure ; sometimes, at least, incurable. The 
obvious alliance with cancer has induced some authorities to 
place lupus in a class of affections called cancroid. It differs 
from cancer, however, in not involving the glands, nor con- 
taminating the general system. Lupus is a comparatively 
rare disease. 

Iodine, as in- LugoPs solution, cod-liver oil, and iron, 
internally, are commonly indicated in the treatment of lupus, 
especially the exedens. Fowler's or Donovan's solution may 
also, or each in its turn, be cautiously given. Chlorate of 
potassium has been suggested. Sea-bathing is likely to assist 
in the treatment. 

Locally, the animal oil of Dippel, made by distillation of 
hartshorn shavings, has a reputation in Europe for lupus 
superficialis as well as for 1. devorans. So have dilute solu- 
tions of chloride of zinc, nitrate of silver, nitric acid, etc. In 
the superficial variety, collodion, softened perhaps by^adding 
1-50 of glycerine, may be painted lightly over the ulceration, 
every day or every few days. 

Excision is sometimes practiced for the exedent form, to 
prevent disfiguration ; but the success of the operation is 
uncertain. So is that of strong caustics. Among these, 
nitrate of silver is preferred by most surgeons. Acetate of 
zinc, used solid for touching the ulcer, and applied every day 
or two, was much recommended by Neligan. He used a lotion 
of the same salt, from three to five grains to an ounce of 
distilled water. Broadbent's treatment for cancer, by injec- 
tion of acetic acid, might be worth a fair trial in lupus. Its 
theory is very plausible. 

Elephantiasis Groecorum. — Called by this name among the 



TUBERCULA. , 459 

Greeks, probably because, as the elephant is a great and 
powerful animal, so is this a formidable disease. It was the 
leprosy of Europe in the middle ages ; for whose treatment 
many hospitals were built, and an order of Christian knight- 
hood (of St. Lazarus) was established. 

It is characterized by many round tumors, from the size of 
a pea to that of an orange, livid, purple, yellowish or brownish, 
and soft, on the face and other parts of the body. ' The skin 
around them thickens irregularly, giving a repulsive aspect. 
Ulceration occurs, deepening even to the bones; all the 
organic functions suffer, and finally the mental faculties be- 
come enfeebled; diarrhoea, and perhaps tetanus, precede death. 

This disease is probably identical with the spedalsked of 
Norway, already named. Allied to it are radesygeoi Norway, 
the morphie of Brazil, frambcesia raspberry disease, Sihbens 
of Scotland, and Aleppo evil, button of Aleppo ; perhaps also 
the Ngerengere of New Zealand. Pellagra, of Lombardy, 
Spain, and France is described by some as having a certain 
resemblance to it ; but tumors do not belong to this disease ; 
in which, with a general cachexia, the skin becomes discolored 
and somewhat thickened, with arrest of its normal functional 
action. 

Treatment of elephantiasis and its allies must be upon the 
principles laid down for other serious cutaneous affections, viz, 
to endeavor to restore the balance of the general functions, what- 
ever may be wrong ; whether that be by tonics, refrigerants, 
or purgatives, or other remedies acting upon the secretions ; 
also improving the nutrition and repair of the skin, by local 
and general alteratives. There is no specific remedy for either 
of the forms of disease last named. 

Keloid. Kelis, Kelois, Cheloid, Sclerema. — This is very 
rare. Yv^ilson, a few years since, stated that but twenty-four 
cases of it were upon record ; more have been reported since. 
An irregular, cicatrix-like, smooth, reddish and whitish, cor- 
rugated excrescence, painful, with a stinging sensation, some- 
times, but not always ; nearly in every case forming upon the 



460 HEMORRHAGIC— PURPURA. 

front of the chest ; slow in growth, not ulcerating, and not 
tender to the touch. It is, not unfrequently, spontaneously 
removed by absorption ; but has not been shown to be amena- 
ble to treatment. Rayer and others advise constant firm com- 
pression. 

Hemorrhagic — Purpura. 

Purpura is the only affection of the skin belonging under 
this head. On parts, or often the whole of the body, appear 
round red spots, which become gradually of a dark purple 
color ; and then pass, as bruise marks do, through green and 
yellow, till they disappear. They are extravasations of blood 
in or upon the true skin from its capillary vessels. The dura- 
tion of each spot is about a week or ten days. Feverishness 
may precede, and prostration may accompany purpura. In 
bad cases, hemorrhages may take place from the mucous 
membranes, as those of the mouth, stomach, bowels, bladder, 
vagina, etc.; producing, sometimes, even a fatal result. 

Purpura is by some improperly confounded with scurvy. 
Although extravasation of blood occurs in scorbutus, it may 
also happen quite independently of it. Deficiency of fresh 
vegetable food is not at all necessary to engender purpura; the 
causation and pathology of which, clinical experience and 
chemical investigation have both failed to show. 

Treatment. — Although some assert plethora to be, as 
often as hydrsemia (anaemia), antecedent to purpura, experience 
goes with the ordinary view, that rather a tonic than a 
depletory treatment is generally called for in it. Excessive 
stimulation, it is true, will aggravate its symptoms. Mineral 
acids, as elixir of vitriol, and Huxham's tincture of bark, or 
quinine, etc, are much given. Oil of turpentine is also 
recommended. Neligan prescribed this in large doses; even 
an ounce at once, with mucilage, and an aromatic. This is a 
very bold use of it; but it is said that it acts generally safely 
as a cathartic in such doses. Ammonio-ferric alum, tincture 
of chloride of iron, tannic and gallic acids, etc., are used as 



NEUROSES. 461 

styptic medicines in some cases. Sponging the body with 
alum and brandy, or whisky, and water, at such temperature 
as is not chilling and yet is sedative to the circulation, will be 
the best local measure. I have used rhus, baptisia, and 
Phytolacca with good results in different cases. 

Neuroses. 

Under this head, of affections involving the innervation of 
the skin, we class Prurigo, Anaesthesia, and Neuralgia cutis. 

Prurigo. — Often placed under papulce, because minute 
pimples occur with it — the essence of this disease is, intense 
itching without eruption. It is commonly divided into 
prurigo mitis, formicans, and senilis. Pruritus is the technical 
name for itching as a symptom. 

The difference between the first two varieties is one of 
degree. In the mitis, obstinacy rather than severity exists. 
In p. formicans, suffering may be extreme, pervading the 
body. Heat of a fire or of a bed, rubbing of the clothes, etc., 
may cause an irritation which drives the prtient to rub and 
tear the skin, yet without relief. Sleep may thus be pre- 
vented, and the bodily as well as mental exhaustion so 
produced may be great. The complaint is occasionally inter- 
mittent. Very often it is confined to one or two portions of 
the body; as the scrotum, vulva, anus (pruritus scroti, vulval, 
ani, vel podicis), etc. Pruritus ani is often caused by worms; 
especially ascarides. 

Prurigo senilis is so named because of its frequency in old 
people. Lice cause it frequently. Papulse attend it more 
often than the other forms. 

Treatment. — This is sometimes a very hard disease to 
cure, or even relieve. We must consider and treat the general 
condition of the body; see that the bowels are regular, the 
digestion normal, the skin kept clean and open by ablutions 
and proper change of clothing. Sometimes nervine tonics 
may be required; as nux vomica, arsenic, or quinine, in small 



462 PARASITICA. 

doses. Tincture of aconite is prescribed by some; three or 
four drops at a time twice or thrice daily. Conium, bella- 
donna, and other narcotics have been advised. The hypo- 
dermic injection of morphia may be resorted to to give rest in 
very distressing cases. 

Locally, many things may, and should, be tried in succes- 
sion, in the search of palliatives. Baths of flaxseed tea, with 
or without carbonate of, sodium or of potassium; lathering 
with castile soap, with a shaving brush; strong salt water, or 
whisky and salt; dilute sulphuric, nitric, acetic, or carbolic 
acid, etc.; these are only a few of the measures which may be 
resorted to. The diet should be unstimulating. Advice 
should be given the patient also to refrain as much as possible 
from violence in rubbing or scratching the parts affected; and 
not to sleep in a very warm room or under too much cover. 

Anaesthesia cutis is only a symptom of a larger affection — 
involving either the nervous system or the skin itself. It 
appears in one variety of elephantiasis Grsecorum, called by 
some lepra ancesthetica. Vitiligo also is often attended by it, 
at the parts which undergo discoloration. Except stimulating 
frictions, when not contra-indicated by the other conditions of 
the case, and galvanism (faradization), under the same limita- 
tions, we have no special remedies to mention for loss of 
sensibility in the skin. 

Neuralgia of the skin, temporarily, at least, limited to it, 
does undoubtedly occur, though seldom. Its locality does 
not, however, so remove it from other forms of neuralgia as to 
require for it a special consideration. 

Parasitica. 

Dermatologists are not all agreed upon the question, 
whether the microphytes or epiphytes (minute parasitic vegeta- 
tions) discovered by aid of the microscope, in connection with 
certain skin dissases, are essential to these diseases, or 
accidental and secondary only. Wilson even denies their 



PARASITICA. 463 

■vegetative nature; asserting them to be results of spontaneous 
granular degeneration of epithelium. Most authorities hold 
the opinion (especially proved by the results of treatment) that 
the parasites are really the essential causes of the disorders 
they constantly attend; that they may, under favorable cir- 
cumstances, be transplanted; and that, to cure those disorders, 
destruction of the parasitic forms is necessary. Again, Hebra, 
a high European authority, believes that all epiphytes 
described are merely modifications of one and the same species, 
indifferent degrees of development. Tilbury Fox agrees with 
this opinion. E. Hallier mekes three series (Mucor, Achorion, 
Leptothryx) of forms, all capable of being educed from the 
same spores under different circumstances. Devergie believes 
in spontaneous generation of the epiphytes, although truly 
vegetable. Dr. McCall Anderson gives proofs, by separate 
inoculation, of the non-identity of three vegetative parasites at 
least — trichophyton, achorion, and microsporon. 

No doubt exists with the large majority of observers as to 
the cause of the animal parasitic eruption, scabies or itch. 

Scabies. — Chiefly vesicular, this disease may be papular, 
scaly, or pustular in some instances. Ordinarily we see, 
especially between the fingers and on the back of the hand, 
next often on the arms, legs, and abdomen, occasionally on 
the scalp, hardly ever on the face — a number of small red 
elevations with white or watery tops. Extreme itching is 
always present ; often keeping the individual scratching night 
and day. 

Closely looking at almost any of the vesicles, one may see a 
little red line or track, at the end of which may be found a 
slightly elevated point. In this is, generally, the animalcule 
— Sarcoptes hominis (Acarus scabiei) ; one of the Arachnida — 
flat-bellied, round-backed, tortoise-shaped, eight-legged ; the 
female larger than the male, which is hard to find. 

Treatment. — Sulphur is not the only, but the most relia- 
ble parasiticide for itch. After thorough bathing, and wash- 



464 PARASITICA. 

ing of the whole body with soap and water, strong sulphur 
ointment must be rubbed well into the parts affected. A few 
applications will usually suffice. The animalcule is killed, 
and the cure follows. There is evidence, however, that in 
some cases of long standing, recovery may follow but very 
slowly. The habit of the eruption has then become estab- 
lished in the skin ; this must be treated like eczema, or lichen, 
whichever it most resembles. 

Oil of turpentine, kerosene, or petroleum, ointment of 
sulphuric acid, and other powerful agents, may be also confi- 
dently relied upon to destroy the itch animalcule. A vinegar 
pack one or two nights often suffices to destroy the cause, and 
promote a cure. 

Army-Itch. — During and since the late war in this country, 
the inevitable filth of camp-life begot, among other evils, a 
very troublesome contagious skin-disease, called by the above 
name. Itching, without any eruption except small papula? 
characterizes it. Outside of the army it has extended to a 
considerable number of persons. No better remedy for this 
affection has been found than a lotion and ointment, composed 
of iodide of potassium and glycerine ; with water or rose-water 
for the lotion, and lard or cold cream for the ointment. Sul- 
phuric acid ointment is also efficacious for it. 

The other parasitic affections of the skin depend upon the 
microphytes already alluded to. They are Favus, Sycosis, 
Tinea circinatus, Tinea decalvans, Chloasma versicolor, and 
Plica Polonica. 

Favus. (Porrigo, Tinea favosa.) — Generally appearing on 
the scalp, this disease is peculiar in the formation of yellow 
cup-shaped crusts, in each of which one or two hairs may 
grow. By joining together, these crusts may lose their regu- 
larity of shape, in a general scabbing ; and a good deal of hair 
may fall out. A mealy powder is found in the crusts, which, 
on microscopic examination, is found to contain the formation 
called achorion Schonleinii by Remak. This presents minute 
tortuous branching tubes, straight or crooked not branching 



PARASITICA. 465 

tubes, and sporules, free or united in bead-like strings. 
Granules and cellules of mycelium, the generative portion of 
the plant, are abundant. An offensive discharge occurs from 
the eruption in bad cases. 

Favus is contagious, though seldom conveyed to cleanly 
persons. It is hard to cure, but not incurable. In its treat- 
ment, constitutional and local measures must be combined. 
Arsenic is the most reliable alterative. Neligan has advised 
the iodide of arsenic, gr. 1-12 thrice daily; intermitted if 
headache or dryness of the mouth come on. 

For the local treatment, the hair must be closely cut with 
sharp scissors. Apply then a large flaxseed poultice for 
twelve hours or more, perhaj^s repeatedly, to soften the crusts. 
JSext, wash the head thoroughly, by means of a soft sponge, 
with solution of carbonate of potassium (one drachm to a pint 
of water) after which ointment of carbonate of potassium 
(potass, carb. 5j, glycerine f5j, adipis Sj) may be applied 
spread thickly on lint^ covered with oiled silk. This may be 
renewed daily; or, if there be much discharge, twice a day. 
The crusts then come away in a few days. Ointment of 
iodide of lead may follow; washing the head night and morn- 
ing, still with the carbonate of potassium lotion ; and keeping 
the hair cropped short all the time. Three or four weeks will 
generally suffice for a cure. Cleanliness of person and regu- 
lated diet are at the same time, of course, essential. 

For this and other parasitic affections of the skin, tar oint- 
ment is a far from contemptible remedy. 

Sycosis (Mentagra). — This occurs on the bearded part of the 
face, chiefly the chin. It is contagious; sometimes being 
transmitted by uncleanly barbers in shaving. It presents 
slightly inflamed elevations about the roots of the hairs, 
covered by scurf; shaving decapitates these, inducing irrita- 
tion and suppuration, as well as scabbing. The whole chin 
may become swollen and inflamed by it; and parts of the 

33* 



466 parasitica. 

beard may be destroyed. The parasitic cause of this disease 
is the trichophyton mentagrophytes (microsporon mentagrophytes 
of Gruby). It is seen under the microscope to consist of 
minute stems, bifurcated at angles of from 40° to 80°, and 
granulated within. 

Sycosis is not common. Acne, impetigo, and ecthyma of 
the bearded part of the face may be confounded with it. It is 
very hard to cure. In its treatment, keeping the beard con- 
stantly very short by close clipping (not shaving) is essential. 
Sponging twice daily with castile soap and water, or carbonate 
of potassium lotion, will be beneficial. Iodide of lead oint- 
ment, and ointment of calomel and camphor may be used in 
succession; besides the internal use of Fowler's solution. 

Tinea circinatus (Ring-worm, Scald-head). — This is known 
by its circular form, occurring most often, though far from 
always, on the head or face. Herpes circinatus resembles it; 
but in that minute vesicles are usual ; in tinea, rare and few. 
In tinea a thin powdery crust exists, whose examination will 
show the trichophyton tonsurans, closely allied to the parasite 
of sycosis. 

Tinea decalvans is marked by a destruction of the hair in 
circular patches, making round spots of baldness. Its parasite 
is considered by many dermatologists as different from the 
trichophyton, and called microsporon Audouinii. Its sporules 
are rounder and smaller than those of trichophyton. 

The treatment of. both forms of tinea must be, besides 
cleansing, essentially paraciticide. Tar ointment; solution of 
corrosive sublimate with care; lotion and ointment of carbon- 
ate of potassium; lotion of sulphurous acid; carbolic acid; 
creasote ; cantharidal collodion, lightly applied ; these are 
among the many applications which may be used for the 
purpose, with generally successful result. 

Tinea is seldom transmitted to a cleanly person without 
very close and continued contact. 



SYPHILIDA. 467 

Chlodsma versicolor (Pityriasis versicolor). — The parasite of 
this is microsporon furfur. The disease is recognized by the 
formation of dull, reddish -yellow spots of various size and 
shape, seldom numerous, on the front of the chest or abdomen. 
The same local applications may be used for it as for tinea; 
besides the internal use of arsenic with usual caution. 

Plica Polonica. — This is an affection of the hairy scalp, 
endemic in Poland, Russia, and Tartary. The hair-follicles 
become diseased, and the hair is matted and glued together 
into felt-like masses. Trichophyton tonsurans and trichophyton 
sporuloids are the parasitic vegetations described as found 
connected with it. The disease has not been seen in this 
country. 

Syphilis— Syphilida. 



Sufficient for our purpose and space has already been said 
of the general history of syphilis. Among its constitutional 
manifestations, cutaneous eruptions are very frequent. These 
are seldom vesicular, not very often papular; most often 
squamous or scabbing. Lepra and rupia, particularly the 
latter, are prominent among syphilitic affections, though 
both may occur independently of syphilis. All erup- 
tions in persons of this diathesis are marked by a coppery 
color, which remains long, even after their cure, by a 
disposition to ulcerate, perhaps only superficially; and 
by preference in locality for the face, shoulders, and 
back. 

In the teeatment of syphilitic eruptions, the diathesis 
must be met by our remedies. Iodide of potassa internally ; 
after that, in feeble persons, cod-liver oil, perhaps iodide 
of iron ; locally, cleansing, besides palliatives, if required, 
as in other eruptions, or medicated vapor bath, should 
be prescribed. Often, such affections will seem to be 
cured, but, after weeks or months, will return again ; 



468 HEMOEEHAGES. 

then the treatment should be renewed, and discontinued 
when they disappear. 



CHAPTER XIII. 
HEMORRHAGES. 



Hemoeehage signifies an escape of blood in its entirety- 
out of the current of the circulation. It may be due to 
rupture of the heart itself, or the blood may come from either 
set of vessels, arteries, capillaries, or veins. Capillary hemor- 
rhages are most frequent in medical practice. As a rule the 
vessels are ruptured, but bleeding may occur, without destruc- 
tion of the walls, as often no lesion can be detected on the 
most careful examination, and it is known that the corpuscles, 
both red and white, can make their w T ay through the coats of 
the vessels. 

The blood may be poured out on a free surface, such as 
that of the skin, or a mucous or serous membrane; or into the 
interstices of tissues, into the substance of organs, or into 
morbid growths. A collection of blood in a solid organ is 
named an "extravasation," "apoplexy," or, under certain 
circumstances, a "hemorrhagic infarct." 

Yaeieties. — 1. Active; 2. Passive; 3. Traumatic; 4. 
Symptomatic; 5. Critical; 6. Vicarious. Local hemorrhages 
are also classified according to the organs from which the 
blood escapes. 

Active hemorrhages are those in which determination of 
blood in excess to the part precedes the bleeding. 

Passive hemorrhages, those in w T hich, from inaction of the 
circulation, or passive dilatation of bloodvessels, congestion 
occurs; or in which the coats of the vessels give way too 
readily, partly from the blood itself being incapable of main- 
taining properly their nutrition. The idea of bleeding by 



HEMORRHAGES. 469 

"exhalation" without rupture of capillaries, is generally 
abandoned. 

Traumatic hemorrhages are those produced by wounds, 
coming thus under the department of surgery. 

Symptomatic hemorrhages are seen in many diseases; as 
epistaxis in typhoid fever; haemoptysis in consumption; 
vomiting of blood in cancer of the stomach; bleeding from the 
bowels in piles, etc. 

Critical hemorrhages are occasional terminations of febrile 
disorders; as of yellow fever, remittent fever, etc. 

Vicarious hemorrhage is that which substitutes one which is 
normal or habitual; as, spitting of blood when the menses 
have been suppressed; or bleeding at the nose following arrest, 
of the bleeding of habitual haemorrhoids. 

Epistaxis. — By usage this term is applied only to bleeding 
from the nose. In young persons, especially from ten to 
fifteen years of age, it is common, and, if moderate, harmless; 
seeming often to relieve a temporary congestion and prevent a 
headache. It is more often seriously troublesome in older 
persons. Generally it is from one nostril only, but not 
always. 

Treatment. — When slight it may be .allowed to stop of 
itself; only not blowing away the clot that forms as a natural* 
plug. If it continue so as to threaten an injurious loss of 
blood, applying cold water to the forehead and nose, or ice r 
there or to the back of the neck, or the roof of the mouth,, 
will generally stop it. If not, a plug of dry cotton may be 
introduced and left in the bleeding nostril. Wetting the 
cotton first in strong alum- water, or dilute tincture of chloride 
of iron, or dipping it in powder of tannin or matico may make 1 
it more effective. When these measures fail, the posterior 
nares must be plugged. Either the watch spring canula may 
be used, or an elastic catheter, having a piece of waxed liga- 
ture or twine passed through its eyelet hole, may be carried 
back from the nostril to the pharynx. Then the string should 
be drawn out of the mouth with forceps, a plug of cotton 



470 HEMORRHAGES. 

should be fastened to it, and drawn by means of the catheter 
till it forces the cotton plug against the posterior orifice of the 
nares. Raising the arms high above the head is a popular 
mode of endeavoring to stop nose-bleeding. 

Bleeding from the Mouth. — This, unless when ulcerative, is 
generally from the gums; as in scurvy. It is, in itself, 
scarcely ever serious in amount. Considerable bleeding, 
sometimes hard to stop, may occasionally follow the extraction 
of a tooth. 

Treatment. — Borax in solution, or tannic acid, or myrrh 
-and rose-water, will be suitable washes for the bleeding and 
spongy gums of scurvy. For hemorrhage after the removal 
t>f a tooth, it may be necessary to plug the cavity with lint or 
cotton dipped in tincture of chloride of iron, creasote or tannic 
acid. 

Haemoptysis. — This term (spitting of blood) is generally 
applied to hemorrhage from the lungs, bronchial tubes, trachea, 
or larynx. Ulceration of the larynx, trachea, or bronchi may 
produce it, not often dangerously. More often the source of 
the blood is the lungs. The diagnosis of this is of great con- 
sequence. Between pulmonary hemorrhage and that from 
the stomach, the following contrast of signs exist: 1. From the 
Lungs. — Dyspnoea; blood coughed up; blood florid, some- 
times frothy; blood mixed with sputa. 2. From the Stomach. 
— Nausea; blood vomited; blood dark, not frothy; blood 
mixed with food. 

In a majority of instances, spitting of blood from the lungs 
is a symptom of phthisis. Cases occur, sometimes, during 
adolescence and early maturity (from 18 to 30 years of age) of 
more or less active pulmonary hemorrhage, whose subsequent 
history disproves a tuberculous origin for it. In these cases, 
there may be immediate danger, more probably than in the 
frequent bleedings of consumption. Aneurism of the aorta 
may also cause haemoptysis, by rupture of the tumor, which 
must cause death. This is rare, and is made known signs by 
already considered. 



HEMORRHAGES. 471 

Treatment. — For active congestive pulmonary hemor- 
rhage, in a young and robust person, it was formerly the 
common practice to take blood from the arm, as a derivant 
measure. But, dry cupping over the chest and back, with 
sinapisms to the legs, and ice, salt, or alum, swallowed slowly, 
the patient at perfect rest in bed, with the head and shoulders 
raised, will be sufficient treatment at the start for most cases. 
Then we should prescribe, if the bleeding continue after the 
first gush, acetate of lead with opium in pill; say a grain or 
two of the former with half a grain of the latter every four, 
three or two hours as the case needs, for a day or two. 

In passive, or tuberculous haemoptysis, rest, with the head 
and shoulders propped, is also necessary. Ice, salt, and alum, 
alone or together, may be held in the mouth and swallowed 
very slowly, till the bleeding has stopped for the time. For 
medicines, in the anaemic, gallic acid, (gr. x to gr. xxx, in 
solution with aromatic sulphuric acid), oil of turpentine (gtt. xto 
gtt. xx in mucilage), and ammonio-ferric alum (gr. v to gr. x), or 
tincture of chloride of iron, are most recommended. But dosing 
with these styptics in consumption is not proper for every 
trifling discharge of blood. They are suitable only when the 
hemorrhage itself is, or threatens to be, a source of additional 
debility. 

Pulmonary Apoplexy. — This is the extremest degree or 
result of congestion of the lungs; hemorrhage occurring into 
the air cells, and obstructing respiration, sometimes to a fatal 
degree. Disease of the heart predisposes to this. Its attack 
is apt to be somewhat sudden; there is great dyspnoea, with a 
purple countenance, and skin rather cold. Percussion 
resonance is dull. On auscultation, at first, a bubbling or 
mucous rale is heard; after the blood coagulates, no respira- 
tory sound at all. 

Treatment. — If diagnosticated early, in a person of toler- 
able strength, cold applications to the chest at once. Then 
(or instead, in a feebler subject), dry cups should be 
applied extensively between the shoulders; followed by a 



472 HEMOEEHAGES. 

large sinapism over the anterior part of the chest, and a hot 
pediluvium. At the same time the reaction which should aid 
in unloading the oppressed lungs (the object of venesection, 
cupping, etc.) may need to be favored by hot drinks, as hot 
lemonade, carbonate of ammonium, or if coldness be decided, 
whisky punch. This is usually fatal. 

Hcematemesis. — Vomiting of blood may result from cancer, 
or ulcer of the stomach, congestion of the liver, aneurism of 
the abdominal aorta, etc. We have given, above, the distin- 
guishing signs between it and haemoptysis. 

Teeatment. — Of course this must be varied according to 
the cause. Slight ejections of blood from the stomach may 
not of themselves require treatment — having only a diagnostic 
importance. In ulcer of the stomach the greatest danger may 
occur, except from rupture of an aneurism. In copious 
hsematemesis, with absolute rest in the horizontal position, ice, 
creasote (one or two drops pro re nata), in solution or pills, 
gallic acid, oil of turpentine, ammonio-ferric alum, or tincture 
of chloride of iron, may be prescribed. Food must be given 
in small quantities and concentrated. 

Hcematuria. — This may be either from the kidneys or from 
the bladder. If the blood is thoroughly mixed with the 
urine, it is probably renal. If the water flows off nearly pure, 
and the blood follows or accompanies the last portion, it is 
vesical. When it follows the use of a catheter or bougie, 
independently of urination, and flows in a stream or in fresh 
drops, it is urethral and traumatic. 

Renal hemorrhage may attend congestion or inflammation 
of the kidney ; or cancer ; or scarlet fever (generally a late 
stage) ; or the irritation of a calculus ; or that of cantharides 
or turpentine ; or, in old persons, it may be passive. In 
Egypt, a parasite sometimes produces it; the distoma hcema- 
tobium. 

Teeatment. — For hemorrhage from the kidney sufficient 
to deplete at all seriously, astringents, as gallic acid, tincture 
of chloride of iron, alum, or acetate of lead, may be used. 



HEMORRHAGES. 473 

Rest is important, in this as in all hemorrhages, during the 
attack. Bleeding from the bladder may be treated by the in- 
jection, through a catheter, of solution of alum or dilute 
solution of creasote (gtt. j. in foj of water) or tannic acid 
(gr. x in f5j). 

Intestinal Hemorrhage. — The causes of this are, especially, 
typhoid fever, of which it is sometimes symptomatic, and 
occasionally critical ; i. e. y the commencement of convales- 
cence. The same may occur in yellow fever, or in remittent 
fever (less often). Aneurism of the aorta, congestion of the 
liver, abdominal cancer, may cause it. Blood is passed, com- 
monly in small quantity, with the discharges of dysentery. 
Aged persons not unfrequently have passive hemorrhage 
from the intestines. Internal piles are very often productive 
of it. The blood from the latter is bright red ; other bleeding 
from the bowels is darker and more mixed. 

Treatment. — Solution of alum by the mouth, with opium, 
or by enema ; tannic or gallic acid, in pill or by injection in 
solution ; oil of turpentine ; creasote, and tincture of chloride 
of iron, or ammonio-ferric alum, are here, as in the other 
hemorrhages mentioned, the most reliable astringents. For 
bleeding piles, special treatment has been already alluded to. 

Vicarious Hemorrhage. —The most frequent instances of 
this are in connection with suppressed menstruation. Epis- 
taxis, hsemoptysis, hsematemesis, renal or intestinal hemor- 
rhage may occur, but it is most apt to be from the stomach or 
lungs. The prognosis in this form of hemorrhage is much 
less serious than in the same of other origin. Its treatment 
should be addressed mainly to the regulation of the disturbed 
or interrupted uterine function. Warmth to the lower ex- 
tremities and back, with such emmenagogues as each case may 
indicate, will generally be required. Astringents are to be 
avoided in vicarious hemorrhage, unless it be in excess of the 
ordinary menstrual or other suppressed discharge. 

Uterine Hemorrhage. — Besides simply excessive menstrua- 
tion, uterine hemorrhage may occur from placenta prsevia 



474 DROPSICAL AFFECTIONS. 

(" unavoidable hemorrhage ") ; abortion ; subsequent to de- 
livery ; uterine cancer ; ulceration of the os or cervix uteri ; 
tumors within, or in the walls of, the womb. 

Treatment. — In considerable uterine hemorrhage, of 
either varie'ty, ergot, in substance or the wine, is likely to be 
of use by promoting contraction of the womb. Ammonio- 
ferric alum is also a good medicine to give by the mouth in 
the same case. Locally, ice or iced water may be (with care 
not to chill too much) applied for a short time over the hypo- 
gastric region, or thrown into the vagina. Tincture of chlo- 
ride of iron, in strong solution, will have a powerful effect. 
Tannic acid or matico may be likewise applied ; or the 
"styptic rod" of tannic acid and cocoa butter, shaped to fill 
the vagina. But threatening cases (except post partum) may 
require the actual tampon, or plug of lint for the whole vagina, 
or the sponge-tent inserted into the os uteri itself. Stimulants 
may at times be called for to prevent fatal exhaustion under 
hemorrhage, either from the uterus or from any other organ. 
Pressure upon the aorta has been sometimes resorted to, 
through the abdominal walls, in uterine hemorrhage. Re- 
cently douching the uterus per vaginum with hot water has 
proved efficient to stop uterine hemorrhage. Other measures, 
suitable after delivery, belong to the department of obstetrics. 
Habitually excessive menstruation requires that the patient 
so affected should maintain absolute rest, from the beginning 
of the flow till its cessation. Iron is nearly always indicated 
in such cases, through the interval ; particularly the tincture 
of the chloride of iron, or ammonio-ferrie alum. 



CHAPTER XIY. 

DROPSICAL AFFECTIONS. 

Varieties. — 1. (Edema, local infiltration of connective 
tissue with serum. 2. Anasarca, general cellular dropsy. 



DROPSICAL AFFECTIONS. 475 

». Hydrocephalus. 4. Hydro-thorax. 5. Hydropericardium. 
\. Ascites. 7. Other local dropsies, as Ovarian dropsy, 
Hydronephrosis, Hydrocele of the testis, etc. 

Causation and Pathology. — Obstruction to the venous 
circulation, arrest of excretion and absorption, and excess of 
vater in the blood, are the three cardinal elements of the 
pathological causation of dropsy. Either one may induce it. 
Disease of the heart or of the liver brings on dropsy by venous 
)bstruction. Disease of the kidney, or the action of cold and 
svet upon the skin may produce it by checking excretion. 
Wasting diseases are liable in their advanced stages to oedema 
ind anasarca, on account of the watery state of the blood. 

Acute general dropsy results from the powerful impression 
of cold and wet, or of the scarlet fever poison, upon the 
system ; suppressing both the action of the kidneys and that 
of the skin at once. Its most common form is anasarca ; but 
it may take that of ascites, hydrothorax, or even, hydro- 
cephalus. When from cold and wet, it is much more curable, 
especially anasarca or ascites, than similar dropsy of visceral 
origin, e. g., from disease of the heart. Albuminous urine is 
quite common in acute general dropsy. 

Hydrocephalus, hydropericardium and hydrothorax have 
been already sufficiently considered. 

Ascites: peritoneal dropsy; accumulation of water in the 
abdomen. The causes of this of greatest frequency are, 
cirrhosis of the liver, and disease of the kidney. It may also 
follow obstruction of the portal vein by cancer, or general 
obstruction of the circulation from disease of the heart, aorta, 
or spleen ; and it is sometimes ascribed to chronic peritonitis. 

Symptoms and Diagnosis. — Often with emaciation of 
the face, neck, and arms, there is great enlargement of the 
abdomen. When this is far advanced, orthopnea exists, from 
pressure upon the diaphragm. The patient is generally 
weak, with poor appetite and deficient rest at night. 

On inspection, in the upright posture, the fullness is greatest 
in the lower part of the abdomen ; when recumbent, it spreads 



476 DROPSICAL AFFECTIONS. 

evenly ; on one side, it falls over that way. Palpation will 
make evident fluctuation, especially when one hand is placed 
on one side of the abdomen, and the other strikes gently at a 
distance of a few inches. Percussion discovers resonance 
above and about the umbilicus, the intestines rising there 
upon the fluid to the surface under the abdominal walls. 
Elsewhere, the sound is dull, even flat. 

The amount of fluid in ascites is sometimes immense ; as 
much as twenty-five pints or more have been withdrawn at 
once by tapping. It is generally clear, pale yellow or color- 
less, albuminous and alkaline. 

Ovarian Dropsy. — Leaving the history of this, as belonging 
to the special department of diseases of women, it is proper to 
state that its diagnosis is important, but not always easy. 
Like ascites, it produces abdominal enlargement, with dull- 
ness on percussion and fluctuation. The most nearly constant 
points of distinction are, that the ovarian tumor begins some- 
what on one side, and only by degrees becomes symmetrical ; 
its shape is, throughout, more globular, and coherent, and 
altered less by changes of position • and the intestines do not 
float up above the umbilicus so as to make a clearness of 
percussion-resonance there. The progress of ovarian dropsy 
is usually slower, and attended by less proportionate depres- 
sion of the general health. 

Treatment of Dropsy. — Acute general dropsy, from 
suppression of the action of the skin and kidneys, should be 
treated by active purgation and the use of diuretics. Jalap 
and cream of tartar (gr. x of the former with 5\j to 5iv of the 
latter), every day or two, will answer well for catharsis. The 
diuretics most satisfactory are the infusion of juniper berries 
(a pint daily), acetate of potassium, citrate of potassium, 
squills, and sweet spirits of nitre. When the patient is hard 
to purge, elaterium or podophyllin may be given, in gr. Jth 
doses, every four hours till it operates. 

Ascites, or other dropsy, from disease of any of the great 
organs, kidneys, liver, or heart, being less curable, and 



DROPSICAL AFFECTIONS. 477 

attended by greater general debility, needs more economy of 
strength. No doubt exists that real harm may be done by 
the routine of severe purging and plying with diuretics. The 
one may render the blood thinner and aggravate the constitu- 
tional disease, while the other, failing to remove the fluid by 
secretion, may even irritate the kidneys to the point of sup- 
pression of their action. Nourishing concentrated food, 
tonics, anodynes, etc., may, in visceral dropsy, be of more 
importance than diuretics. Of course it is desirable to 
lessen the accumulation of fluid ; but the effects of the reme- 
dies used must be observed, and one symptom must not be 
allowed to overshadow all the rest. 

When enormous distension makes rest impossible, and 
almost prevents breathing, it is necessary to relieve it by any 
possible means. Then purging, as by elaterium or podo- 
phyllum should diuretics fail, must be resorted to. Or, if the 
patient's stomach or general strength will not bear that, 
paracentesis, tapping, is called for. Some patients require 
this many times. 

The operation is best performed while the patient is lying 
down upon the side, near the edge of the bed. A trocar and 
oanula are introduced half-way between the pubes and the 
umbilicus, and the fluid is drawn out through the canula. 
Then a bandage, with a compress, is applied firmly around 
the abdomen. Some practitioners favor keeping open the 
orifice with a slip of lint, to maintain drainage. If no local 
irritation occur, threatening peritonitis in consequence, this 
may be a serviceable measure. If the bolder practice of in- 
jecting iodine after tapping, as in hydrocele, should be thought 
of in any instance, it must be in the case of simple peri- 
toneal dropsy, uncomplicated by serious visceral disease. 

Sometimes oedema of the lower limbs and scrotum becomes 
so great as to cause great inconvenience. Then the fluid may 
be let out by making a number of small punctures with an 
abscess lancet or small pointed bistoury. The only drawback 
to this is the possibility of erysipelatous inflammation about 



478 INTESTINAL WORMS. 

the punctures. Such danger will not be at all great if, 
immediately after the operation, the parts be soothed by bath- 
ing or anointing the skin with diluted glycerine (f5j in f§j of 
rose-water), or cold cream (ung. aq. ros.), or glyceramyl 
(glycerine and starch) or with vasolin. 

For the treatment of ovarian dropsy, the reader is referred 
to Surgery. 



CHAPTER XV. 

INTESTINAL WORMS— ENTOZOA. 

Helminthology , the study of worms, has assumed importance 
in connection with medicine. About thirty entozoa inhabit 
different parts of the body of man. They have been generally 
classified as Codelrnintha, or hollow worms, and Sterdminthc 
or solid worms, as without any well-defined alimentary cavity. 
Broad or flat worms, Platelmia, and thread-like or cord-shaped 
worms, Nematelmia, constitute another arrangement. Of the 
flat worms, some are Cestoid, or ribbon-like; others Trematode, 
or flute-like. The most important ones are enumerated in the 
the following table : 1 . Cestoid Worms : Mature : Taenia 
solium; taenia mediocanellata ; taenia echinococcus; bothrio- 
cephalus latus. 2. Immature: Cysticercus cellulosse; echin- 
ococcus hominis; Cysticercus t. mediocanellatse. 3. Trematode 

Worms : Distoma hepaticum (fasciola hepatica) \ distoma 
ophthalmobium ; bilharzia hseniatobia ; tetrastoma renale. 4. 
Nematoid Worms: Ascaris lumbricoides; trichocephalus dis- 

par; oxyuris (ascaris) vermicularis. 5. Sclerostoma duodenale; 

filaria medinensis; strongylus gigas. 6. Trichina spiralis. 

Taenia solium and tamia mediocanellata look a good deal 
alike; but the former is much smaller. The immature 
cysticercus of the former is 9-10 of an inch long; that of the 

latter, of the size of a pea. The t. solium has a circle of hook- 



INTESTINAL WORMS. 479 

lets around a convexity of the head; the medio canellata is 
club-headed, with larger sucking disks than the solium. One 
is designated as "arined" and the other "unarmed" tapeworm. 
The former (t. solium) is from the cysticercus cellulosce of the 
hog; the latter from the "cysticercus bonis"* (Cobbold); and is 
the most common. The unarmed is the easiest to drive out. 

The tapeworm is formed of flat segments, often several 
hundred in number, connected with the head by a slender 
neck. Each segment has male and female organs (herma- 
phrodite); as those at the tail mature, they are cast oif. Some 
patients thus pass six or eight fragments from the bowels in a 
day. The whole length of the parasite is from ten to thirty 
feet or more. 

The symptoms caused by tapeworm are not very determin- 
ate. They resemble those produced by other worms; namely,, 
uneasy sensation in the abdomen, and general nervous irrita- 
tion ; bad sleep, attacks of faintness, and lowness of spirits, 
indigestion, irregularity of appetite and of the action of the 
bowels ; itching of the nose, and sometimes of the anus. 
Epilepsy and insanity are said to have sometimes been caused 
by it. The only proof of tapeworm is the finding of frag- 
ments of it in the stools. It is a common impression that it is 
never destroyed unless the head is discoverable; but this is 
not exactly true. Conversely, if the head comes away, the 
parasite to which it belongs is no longer reproduced. More 
than one of them may, however, be present at once ; though 
this is rare. 

The broad tapeworm, hothriocephalus, is known only in 
Northern Central Europe ; Eussia, Sweden, Norway, Lapland, 
Finland, Poland, and Switzerland. Its head is elongated, 
compressed, obtuse; its length from six to twenty or twenty- 
five feet. It does not give off detached segments. Cobbold 
says it is indigenous to Ireland; although he has never met 



♦Cobbold states that the hydatid of the cysticercus bovis has never yet 
been observed in man. Hydatid or "echinococcus" disease is especially 
frequent in Iceland. 



480 INTESTINAL WORMS. 

with a patient born in that country who has been the subject 
of it. 

Prognosis. — Most worms may be readily got rid of if 
properly treated. Tapeworms are sometimes difficult to 
remove completely, but with systematic management a cure 
may almost always be effected. It is safest to see that the 
head of a tapeworm is discharged, else, if this remains, a 
further growth will probably take place; however, it is 
affirmed that if only the head and a small portion of the neck 
is left the worm will die; and further, the nearer the head any 
portion is which is detached, the more easily will the rest be 
got rid of. Worms may now and then prove highly danger- 
ous by their migrations, or by causing obstruction of the 
bowels; death may also occur from reflex convulsions excited 
by them. 

Treatment. — If worms are present, the first object in 
treatment is to get them expelled. The remedies must vary 
with the nature of the parasite. For tapeworm the following 
plan of treatment is usually efficacious. To let the patient 
take only liquids, such as milk and beef tea, for a day, then to 
administer a full dose of castor oil in the evening, and finally, 
early on the following morning, if the oil has acted well, to 
give a draught containing the liquid extract of male fern, in a 
dose of 10 drops to 5i or 5iss., according to age. The draught 
may be made up with sugar, mucilage, and milk, or with the 
yolk of an egg and cinnamon-water. The object is to clear 
out the bowels so as to expose the worm, and then the male 
fern acts upon it and kills it. Sometimes it is desirable to 
follow this up by another dose of castor oil, but generally this 
is not needed, as the drug itself acts as a purgative. Some 
prefer the powdered fern. In order to see whether the head 
is discharged, each stool must be received into a separate 
vessel, then mixed with water and filtered through coarse 
muslin. 

Other anthelmintics employed for the destruction of tape- 
worms are kousso, followed by a cathartic; hamela powder 



TREMATODE WOEMS. 481 

5i to 5iij in treacle or syrup ; decoction of the bark of the 
root of pomegranate, §ij in Oj, boiled down to Oss.; powdered 
areca nut; oil of turpentine, 5i to 5ss.; and petroleum, xx to 
xxx drops. If the worm projects through the anus, it has 
been recommended to roll it gradually round a piece of stick, 
and thus draw it out, or to apply some poisonous agent to the 
protruded portion. Kamela, the Rottlera tinctoria of botanists, 
infusion of pumpkin seeds, plentifully taken on an empty 
stomach, are quite effectual. 

Prevention of Tapeworm. — As immature tapeworms find 
residence in the bodies of animals used for food, and thus get 
the opportunity to enter the human alimentary canal, the 
avoidance of raw or under-cooked meat is the precept of 
prophylaxis suggested and confirmed by experience. This 
-applies not only to the prevention of tapeworm, but, also, to 
that of other parasites, especially trichinae. Tapeworms are 
-derivable from infested beef, even oftener, (Cobbold) than 
from pork. Mutton has been found occasionally to contain 
■cysticerci. 

Teematode Worms. 

These are the Distomata, Bilharzia hcematohia, Tetrastoma 
renale, and others. They are of a flattened oval shape, soft 
and smooth. They have a bifurcating alimentary canal, with 
n mouth, but no anus. Both sexes in distomata are upon one 
individual. They exist in two conditions, mature and 
encysted, and immature and free. Their methods of repro- 
duction are very curious, but of greater importance in 
.zoological than in pathological science. 

Distoma hepaticum, found sometimes in the liver and its 
•ducts, measures about an inch in length when mature, and 
rather less than half an inch in width. 

Distoma ophthalmobium has been found in the eye of a 



482 NEMATOID, OR ROUND WORMS. 

child having congenital cataract. It is about half a line (1-24 
in.) in length. 

Bilharzia (or distoma) hcematobia is found in great abund- 
ance in Egypt; where it inhabits the veins of the abdominal 
organs of the inhabitants, in the proportion of nearly one- 
third of the population. Hemorrhage from the kidney, and 
the symptoms of dysentery, may follow from its presence. It 
is not more than three or four lines (J to i in.) in length. 
The sexes are on different individuals. 

Tetrastoma renale is occasionally found in the substance of 
the kidney. It is nearly half an inch long. 

Nematoid, or Round Worms. 

Ascaris lumbricoides is the commonest of entozoa. It 
inhabits mostly the small intestines; but may get into the 
stomach, and of course, the large intestines. This round 
worm is from five to fifteen inches in length, light brown in 
color, tapering to a point at each end. A considerable num- 
ber of them may exist together; it is only then that their 
presence in the bowels is likely to do much harm, uuless in 
very susceptible children. Their escape into the stomach may 
cause nausea, vomiting, and indigestion, sometimes difficult to 
account for until the throwing up of the worm explains the 
cause. These worms probably enter the body chiefly in the 
drinking water of shallow wells, muddy streams, etc. 

Treatment; Diagnosis. — Two things are wanted: to 
expel the worms present, and to prevent their reaccumulation. 
As to the evidence of the existence of lumbricoid worms in 
the bowels, it is always doubtful unless some of them pass out 
with the evacuations. Signs of gastro-intestinal and nervous 
irritation attend them, especially in infants and young children. 
So, grinding the teeth during sleep, itching of the nose and 
anus, bad or irregular appetite, and tumidity of the abdomen, 
are regarded commonly as signs of worms. But other sources 
of indigestion and disturbance may be thus made known. 



OR ROUND WORMS. 483 

Convulsions may undoubtedly be caused by worms in chil- 
dren ; and so may laryngismus stridulus and spasmodic 
croup. 

When there is good reason to believe that they do exist in 
the bowels, anthelmintics may be given, with purgatives, in 
safe doses, watching their effects. Besides the vermicides 
mentioned in connection with tapeworm, many other drugs 
have more or less of such effect; as santonin (most certain of 
all,) pinkroot (spegelia) bark of pomegranate root, azedarach, 
chenopodium, cowhage (mucuna), powder of tin, etc. 

Infusion of senna and spigelia, half an ounce of each to a 
pint; for an adult, a wineglassful every morning before 
breakfast; this is very popular and often effectual. Instead 
may be given fluid extract of spigelia and senna, a teaspoonful 
for a dose. As above said, santonin is the most effectual ot 
the vermicides or vermifuges. It requires care in its use, 
however; producing serious vomiting, prostration, and nerv- 
ous symptoms in over-dose. A child should not take more 
than half a grain of santonin once 'or twice daily; an adult, 
from three to six grains. 

Trichocephalus dispar. — This worm inhabits the large intes- 
tine. It has a length of an inch and a half to two inches. 
The head is attenuated or hair-like; whence its name. The 
sexes are on different individuals. The trichocephalus is 
much less common than the lumbricoid worm. 

Oxyuris vermicularis (Ascaris vermicularis) . White seat- 
worm. — Of this the male is about a line (1-12 in.) and a half 
long; the female five or six lines. It is found in the rectum, 
generally of children ; sometimes in considerable numbers. 
They cause a great deal of itching; occasionally, other 
nervous irritation. Females may have them to find their way 
into the vagina; more rarely, they get into the urethra. 

For treatment of seat-worms, nothing is equal to supposi- 
tories of santonin; made with cacao butter, three grains of the 
drug in each ; one to be introduced into the rectum every 



484 TRICHINA SPIRALIS. 

niglit. Other common remedies are, injections of lime-water, 
infusion of aloes, salt water, etc. 

Trichina spiralis. — Zenker of Dresden first showed that, 
although a few trichince may be innocent, they sometimes 
abound to such an extent as to cause serious disease, and even 
to destroy life. Such an affection is called trichinous disease, 
trichiniasis or trichinosis. It has occurred particularly often 
in Germany, where it has been recognized since 1860. The 
first cases in America were reported by Dr. Schnetter of New 
York. At Marion, Iowa, in 1866, nine cases occurred in one 
family ; five died. In the same county, eating raw ham con- 
taining trichinae, as proved afterwards by examination, caused 
the disease in six children at once. An examination of pork 
in Chicago by a committee of the Academy of Sciences of that 
city proved the existence of trichinae in 1 in 50 of the hogs 
inspected ; some of their muscles containing from 10,000 to 
18,000 in a cubic inch. Such animals are not themselves 
nearly always out of health. Cattle, also, are to a less degree 
subject to the same parasite. The 'meat of those so infected 
should of course not be used for 'food. In some German 
cities the butchers have microscopic examination made of the 
flesh of all their animals. 

To the naked eye, the muscles of a trichinous animal present 
whitish dots, which a lens will show to be the capsules or 
cysts of immature trichinae. Those not encysted are invisible 
without a microscope. The capsule is hard and transparent; 
the worm is coiled spirally within it. Under the tougue is 
the preferred place to search for the trichinae in the living 
animal ; a delicate harpoon being used. 

The trichina is a small bi-sexual worm, reproducing in the in- 
testinal canal of animals or men; the offspring then finding their 
way out through the walls of the intestines to become finally 
encysted in the muscles. The disease produced by them has 
two distinct stages : 1, that of the presence of the .worms in 
the alimentary canal, and their multiplication there ; 2, that of 
their migration to and location in the muscles. Of the first 



GUINEA WORM. 485 

period, malaise, vomiting, and diarrhoea are the leading symp- 
toms. Of the second, fever resembling typhoid, severe pains, 
with stiffness in the muscles, and prostration. As the muscles 
of the larynx are often attacked, hoarseness is a common 
symptom. The complication of pneumonia is not infrequent. 
The first stage above mentioned lasts about a week or less ; 
the second may terminate fatally within six days, but usually 
has a duration of from two to four or five weeks. 

I am not informed of any success with the treatment of 
trichiniasis. Its prevention is always possible. Besides 
proper inspection of animals, every piece of meat which may 
be suspected must be well coohecl. Reliance cannot be had 
upon salting and smoking; at least unless they be very 
thoroughly done. 

Sclerostoma duodenale is common in Egypt and in parts of 
Europe. It exists in the small intestines, and causes a chlo- 
rosis-like anaemia. This worm is from a third to half an inch 
long. Its vermicide is said to be turpentine. 

Strongylus gigas (Eustrongylus gigas) inhabits the kidney. 
It is rare in man. 

Filaria medinensis (Dracunculus) or guinea-worm lives in 
the subcutaneous tissue. It is common in the tropical regions 
of the old world. The female worm it is, that enters the skin 
of a human being, and develops, with its contained young, in 
a whipcord-like shape, to a length varying from six inches to 
four, five, or six feet, and a width of about one-twelfth of an 
inch. A dozen or more of the worms may exist upon the 
same person. The lower limbs are especially invaded by 
them ; but they can migrate almost all over the body. They 
evidently get into the legs and feet of those who bathe in 
shallow streams or ponds, or walk barefooted in damp and 
muddy places. An incubation of a year or more is required 
for the development of the worm to a perceptible size. 

A characteristic vesicle appears, generally upon the lower 
part of the leg, when the worm matures. This bursts, emit- 
ting the young filarise ; a good deal of itching and irritation 



486 THE PLAGUE. 

ensues, and sometimes ulceration. The natives often rid 
themselves of the worm by letting a stream of water run or 
pour for a time upon the leg. When it creeps partly out, they 
draw upon it until it is dislodged. 



CHAPTER XYI. 



"BLACK DEATH"— PE8TI8 BUBONICA OB BUBO 

PLAGUE. 

I have thought proper to briefly notice the epidemic now 
raging in the southern provinces of Russia, as a subject / of 
general interest. 

The large number exposed to the contagion who are 
attacked, its rapid spread, the short interval — only some 
hoars in many cases — between the appearance of the first 
symptoms and death, and the enormous mortality, from 
eighty-five to ninety per cent, of those attacked, are all 
characteristic of the plague. I know of no exanthematous 
disease so sudden in its onslaught, with high fever, frequent- 
pulmonary complications, and glandular swellings, especially 
in the groin, except the plague. 

These buboes, where death has not intervened before their 
appearance, are sufficient to distinguish the disease from 
typhus fever of however malignant a type. In all descrip- 
tions of the disease, whether ancient or modern, they occupy 
the prominent place, and so pathognomonic have they been 
regarded that the term pest or plague, at first applied to every 
very fatal epidemic, became long since synonymous with 
pestis buboniea, or bubo plague. It is not probable that the 
Russian government has at any time since the middle of 
December been ignorant of the real nature of the disease, and 
greater frankness and consistency on its part would have dis- 



THE PLAGUE. 487 

armed the extravagant rumors circulated, given confidence to 
its neighbors, and caused no more injury to commerce than 
the course it has pursued. 

The epidemic had assumed serious proportions by the 25th 
of November, 1878 ; the government was only officially in- 
formed of it on the 11th of December; ten days more elapsed 
before any systematic or energetic means were taken for pre- 
venting its spreading, since which time the authorities have 
exerted themselves to the utmost. The precautionary meas- 
ures adopted are as against the plague : the erection of the in- 
fected districts into a distinct province with its governor ; the 
establishment of quarantine stations on the borders of this 
district, and of a double cordon militaire; an entire cessation 
of intercourse as far as possible, even postal communication 
except after thorough disinfection ; the wholesale destruction 
by fire of depots of provisions, and even villages, — still so late 
as January 18th the government, though acknowledging a 
mortality of not less than eighty -four per cent, of the attacked, 
was using the terms "the epidemic," "the disease," "malig- 
nant typhus," "galloping typhus with pneumonic complica- 
tion," represented the disease as diminishing; at the same 
time private intelligence represented the disease as increasing, 
and it was openly called the plague in a St. Petersburg med- 
ical journal. This want of candor has tended to increase the 
panic and foster exaggerated rumors. Intelligent precautions 
have been taken in Moscow, as the closing of all basement 
dwellings, the erection of clean temporary buildings, of 
furnaces to burn infected clothes, and the gratuitous distribu- 
tion of cooked food ; the report that cases of the disease had 
occurred there or at Lower Novgorod was premature. The 
latest available accounts give reason to suppose that the 
disease as an epidemic has not appeared to the north or west 
of the quarantine station of Zaritzin. A telegram announces 
the appearance of the plague in Thessaly, and any day may 
modify the situation. The infected district is in the lower 
valley of the Volga, near the Caspian Sea. The sanitary lines 



488 THE PLAGUE. 

extend on both sides of the river, a distance of one hundred 
and fifty miles. Zaritzin, a town of fifteen thousand inhabi- 
tants, and a quarantine station, is at the northwestern extrem- 
ity of this district on the Volga, and Astrakhan, the capital of 
the province, at the southeastern extremity. There has been 
no outbreak of the disease in the town of Astrakhan. Its first 
appearance was in the village of Wetlianka, where it was in- 
troduced in the booty of returned Cossacks, which had 
escaped disinfection. From whence these Cossacks had 
returned we do not know, but it is certain that plague has 
been prevalent in the Persian province of Ghilan, at the 
southwest corner of the Caspian, since 1876 ; the intercourse 
of Russia with Persia is through the ports of this and neigh- 
boring provinces, and precautions have been taken by Russia 
for some time back against the ' introduction of the disease 
from the Persian province. 

The sparse population of the infected country, one to three 
to the square verst (two-thirds of a square mile), the spread 
of the disease has been rapid, its progress about thirty 
miles in three days. It seems to have followed the Volga, 
but Zaritzin is connected by rail with the entire net-work of 
Russian railways and with the rest of Europe, and the valley 
of the river Don, which flows into the Sea of Azof, here 
approaches very near the valley of the Volga. Should this 
point be invaded there would be great cause for general un- 
easiness. Hecker's Epidemics of the Middle Ages vividly 
portrays the progress and consequences of the black death of 
the fourteenth century. 

This terrific visitation of disease records one of the most im- 
portant events in the history of modern civilization. It sur- 
passed all other epidemics of bubo plague. The first extensive 
epidemic in Europe occurred in the middle of the sixth 
century, in the reign of Justinian, and is known by his name ; 
its last appearances were in Malta in 1813, in Noja, Lower 
Italy, in 1815, in Majorca in 1820. It is a mistake to suppose 
that plague only a disease of the past ; cases are probably 



THE PLAGUE. 489 

always to be found in parts of Persia and Syria, and at various 
times since and before the Christian era. 

In comparison with past epidemics Europe has in its favor 
at present the greater cleanliness and better ventilation of its- 
towns, and the better knowledge of sanitation in quarantine 
and disinfection ; but the disease is favored by the great 
rapidity and intricacy of communication between different 
points, and the difficulty of making practical application of 
our increased knowledge. Notwithstanding the virulence of 
the plague of the fourteenth century there elapsed three years 
from its exportation from Syria in 1347 to its introduction 
into Russia in 1351, and this was effected by the way of 
Sweden and Norway, after it had made the complete circuit of 
Europe. It took the disease three months to travel from the 
coast of England up to London. There has always been 
much difference of opinion as to whether the plague is a di- 
rectly contagious disease, and it is perhaps better to regard the 
question as an open one still. Liebermeister calls attention to 
the fact that the same discussion has been and is still going 
on in relation to typhoid fever, cholera, and dysentery, and 
classifies the plague with them among the contagious mias- 
matic or indirectly contagious diseases. The contagion is 
certainly, as a rule, indirect, that is through clothes and other 
effects, and not directly transmitted from individual to indi- 
vidual. The stage of incubation is given at from two to 
seven days, but the plague poison is supposed to be capable of 
living a very long time under certain conditions outside the 
human body. No proper treatment is yet settled. 

The season of the year and climate have very slight influ- 
ence upon the disease, but moderate w T armth with dampness 
seem favorable to its propagation. It is not a disease of 
tropical climates, and the extremes of temperature, though not 
hindering the spread of the disease, diminish it. The epi- 
demic of the fourteenth century is reported to have attacked 
the robust by preference. Though far removed from its seat 
he present epidemic is of great interest to us in the United 



490 INHALATION AND ATOMIZATION. 

States in its character and progress. It offers us an opportu- 
nity to observe the application and efficiency of various sys- 
tems of quarantine upon an extended scale, and of methods of 
disinfection, from which much may be learned of value in 
dealing with those epidemics which threaten our own part 
of the globe. It is important that medical men thoughtfully 
watch this epidemic, and acquaint ourselves with epidemic in- 
fluences and the means of crashing epidemics of every form 
and character. 



CHAPTER XVII. 
INHALATION AND ATOMIZATION. 

Palliation of pulmonary and bronchial or laryngeal irrita- 
tion, or diminution of excessive expectoration, as by simple 
vapor of water, tar-vapor, or that of infusion of hops, poppy 
leaves, etc., has been often realized. 

For ordinary inhalation, simple apparatus will suffice. A 
wide-mouthed bottle, with a cork in it; the cork pierced by 
two glass tubes, one straight, reaching near the bottom ; the 
other short and bent outside of the cork. The bottle not 
quite filled with the liquid (heated according to its volatility); 
the bent tube not reaching its surface, the other conveying air 
into it beyond the cork. This is not necessary, in the case of 
liquids used with water. We may employ these by pouring 
boiling water into a convenient vessel, the medicament added 
to it. Cover the vessel with a towel, hold the mouth and 
nostrils under the edge of the latter. Hops, in infusion, 
stramonium leaves, or laudanum, etc., may be used. Of 
laudanum, twenty or thirty drops in a pint of water, for 
worrying cough. Smoking is a primitive method of inhalation. 
Tobacco, so used, sometimes relieves in asthma; but cigars of 



INHALATION AND ATOMIZATION. 491 

stramonium leaves, or of paper saturated with nitrate of 
potassium, are more effectual in the paroxysms of the disease. 

Recently minute division or atomization of liquids, intro- 
duced into the air-passages, has been substituted for inhalation. 
Under the fascination of novelty, the imposing appearance of 
instrumental appliances, a degree of enthusiasm has existed 
about it. It is an important means of treatment of the throat, 
and lungs. Referring to special works for details, I give but 
a brief account of atomization or nebulization. 

The idea is, forcing a fine jet of liquid against a solid body, 
or a strong current of air, so as to convert it into diffused 
spray. Bergson employed the tubes used for odorators, to 
spread perfumed liquids in the air. Two glass tubes with 
minute orifices are fixed at right angles, the end of the up- 
right tube is near and opposite the centre of the orifice of the 
horizontal tube. The upright tube, immersed in the liquid to 
be nebulized, air is forcibly blown through the horizontal one. 
The current of air, passing over the outlet of the tube com- 
municating with the liquid, rarefies the air, causing a rise of 
the liquid in the tube, and its minute subdivision (atomiza- 
tion, nebulization, pulverization), as it escapes. Silver tubes 
instead of glass are harder to keep clean. Glass ones may be 
cleaned with muriatic acid solution, aided by a bristle to 
remove obstructions. The form of tubes may be varied, to 
adapt their application to any part of the body. 

Richardson's spray-producer consists of a graduated bottle, 
through whose cork passes a double tube, a tube within a 
tube. The inner reaches near the bottom of the bottle, below, 
and above to near the extremity of the outer tube. The 
latter has entering it, above the cork, another tube connected 
with "hand bellows," — or, two elastic bags, the one nearest 
the bottle (protected by silk network) acting as an air-cham- 
ber, the farthest being compressed by the hand to produce a 
jet of air into the boti^e and tube. 

An apparatus for the application of steam-power to atomiza- 
tion : a small boiler is connected with the horizontal tube: in 



492 INHALATION AND ATOMIZATION. 

the boiler steam is generated by a spirit lamp. The jet of 
steam from the horizontal tube nebulizes the liquid drawn up 
from the vertical tube immersed in a vessel containing it. 
The steadiness of action of the steam-apparatus is a great 
advantage; for many purposes, the hand-ball atomizer is more 
available. 

For effectiveness of inhalation, in chronic or subacute cases, 
the patient must have the instrument at home, learn its man- 
agement, and use it with regularity for a sufficient time. 

First inhalations should be short, with warm water, to 
inure the patient to their use. The distance of the mouth 
from the tubes vary from six inches to two feet. When pre- 
pared, one may inhale "medicated spray" for ten minutes; 
breathing deeply so that the liquid reach the remote air 
passages. It should not be done after a hearty meal; the 
patient should remain in-doors a while after the inhalation. 

Proof has been obtained that atomized liquids inhaled do 
pass into the trachea; constantly into the larynx. A certain 
portion may reach the lungs. Trial has been made of this 
process in croup, diphtheria, oedema of the glottis, catarrh, 
chronic laryngitis, whooping-cough, asthma, pulmonary 
hemorrhage, and phthisis favorably. 

False membrane has been asserted by Kuchenmeister, Bier- 
mer, Geiger, and others to be dissolved, or removed from the 
throat, by inhalation of hot lime-water. Cause the patient to 
breathe the vapor arising from hot water poured on unslaked 
lime. 

Dr. Da Costa says : "In most acute diseases of the larynx, 
more so in acute disorders of the lungs, the value of inhala- 
tions of atomized fluids, save in so far as those of water may* 
tend to relieve the sense of distress, etc., and aid expectora- 
tion, is very doubtful; though in some acute affections, as in 
oedema of the glottis and in croup, medicated inhalations have 
strong claims to consideration. 

"That in certain chronic morbid states of the larynx, par- 



HYPODERMIC MEDICATION. 493 

ticularly those of a catarrhal kind, and in chronic bronchitis, 
they have proved themselves of great value. 

"That in the earlier stages of phthisis, too, they may be of 
decided advantage, 'and that at any stage they may be a 
valuable aid in treating the symptoms of this malady. 

"That their influence on such affections as whooping-cough 
and asthma is not satisfactorily proven. 

"That they furnish a decided and unexpected augmentation 
of our resources in the treatment of pulmonary hemorrhage. 

"That they require care in their employ ; and that in acute 
affections we should consider whether, as they have to be used 
frequently to be of service, the patient's strength justifies the 
disturbance or the annoyance their frequent use may be." 

Doses for Inhalation. — Alum, 10 to 20 grs.; tannin, 1 
to 20 grs.; perchloride of iron, J to 2 grs.; nitrate of silver, 1 
to 10 grs.; sulphate of zinc, 1 to 6 grs.; chloride of sodium, 5 
to 20 grs.; chlorinated soda, J to 1 drachm; chlorate of potas- 
sium, 10 to 20 grs.; chloride of ammonium, 10 to 20 grs.; 
watery extract of opium, J to J grs.; fluid extract of conium, 
3 to 8 minims; fluid extract of hyoscyamus, 3 to 10 minims 
tincture of cannabis indica, 5 to 10 minims; LugoPs solution 
of iodine, 2 to 15 minims; Fowler's solution of arsenic, 1 to 
20 minims; tar water, 1 to 2 drachms; oil of turpentine, 1 to 
2 minims. 



CHAPTER XVIII. 
HYPODERMIC MEDICATION. 

Hypodermic injection of medicinal substances is safe; more 
rapid, certain, and exact, in proportion to the amount, than 
medication by the mouth. It requires one-third or one-half 
the quantity necessary when given by the stomach; produces 
less complicated and less inconvenient results. 

The medicines mostly used are narcotics, sedatives, and 
nervine tonics. It is in symptoms affecting the nervous sys- 



494 HYPODERMIC MEDICATION. 

tern that the greatest number of successful cases has been 
reported. Pain is speedily relieved by it. Hunter says : 

"When the immediate and decided effect of the medicine is 
required. 

"When medicines administered by the usual methods fail to 
do good. 

"Where the effect of a medicine is required, and the patient 
refuses to swallow. 

"Where, from irritability of the stomach, or other cause 
(such as idiosyncrasy, etc.), the patient cannot take the 
medicine by the stomach." 

The instrument approved is a small glass syringe, holding 
about half a fluidrachm, graduated for drops or minims, with a 
tube for puncture, of tempered steel, or of silver with a gold 
point. The end of the tube must be small and sharp. If the 
dose of the medicinal agent be not too large, the only danger 
(unless in an erysipelatous patient) is of a circumscribed in- 
flammation. Repeated injections should not be made at the 
same spot. Draw the skin tense with forefinger and thumb of 
the left hand, and pass the point quickly and steadily through 
it. Then push in slowly the desired amount of the fluid. 
Avoid subcutaneous veins ; the puncture of one of them may 
give rise to an excessive action of the medicine. Glycerine 
may be used as a vehicle instead of water. 

The agents most used are morphia, atropia, strychnia, and 
quinia. For anodyne purposes, Dr. Ruppaner prefers liquor 
opii compositus, one hundred drops are equal to a grain of 
sulphate of morphia. Many use the ordinary solution of 
morphia (gr. j of morph. sulph. in foj). Doses are as 
follows : — Sulphate of morphia, gr. ^ — J ; sulphate of atropia, 
gr. 1-60 — 1-30; muriate of strychnia, gr. 1-24 — 1-8; aconitia, 
gr. 1-30; liq. opii compos., gtt. v — x; sulphate of quinia, 
gr. i — iv. 

These for neuralgia, hysteria, cancer and ulcer of the 
stomach. A case of the latter affection is recorded in which 
for weeks or months the patient was only able to retain food 



HYPODEEMIC MEDICATION. 495 

upon the stomach after the disposition to vomit had been 
allayed by a hypodermic injection of morphia. Curative effect 
has been asserted in cases also of delirium tremens, mania, 
and tetanus; from quinine (two to four grain doses) in inter- 
mittent fever. 

Tentative use of the same mode of practice is justifiable in 
cholera, hydrophobia, poisoning (as the injection of morphia 
for belladonna poisoning, and the converse), violent whooping- 
cough (atropia), pernicious fever, cerebro-spinal fever, heat- 
stroke, etc. 

That the operation is always without inconvenience to the 
patient is not true. Not only pain but local inflammation and 
even suppuration may sometimes be induced. But many 
patients, suffering painful complaints, have had a hundred or 
more injections made in different parts of the body, without 
any disadvantage, and great relief. Caution is necessary to 
prevent the habit of using hypodermic injections of morphia; 
in some instances, it has been known to become as inveterate 
an indulgence as the habit of taking laudanum or smoking 
opium. 



CHAPTER XIX. 
NATURAL THERAPEUTICS. 

The marked tendency of modern practice is to rely more 
upon the resources of nature and to dispense less drugs. The 
latter are very useful, of course, when wisely employed, but 
when given to excess or in depressing doses they are always 
pernicious. The former are the principal means of permanent 
relief and indispensable to health. 

Rest is one of the chief natural therapeutic agents, often the 
only one available or required. Warned through weariness 
of fatigue, exhaustion or pain, all other living beings, and 



496 NATUKAL THEEAPEUTICS. 

uncivilized man seek rest and are restored from their few 
maladies without other aid. The quiet child who most sleeps 
most thrives ; the restless, wakeful child shows little proof of 
active nutrition. The healthy infant passes a greater portion 
of time in sleep and rest. Growth — the normal renewal o 
some parts, and the fresh development of others require rest 
and sleep. Many well known grave maladies are curable 
only through absolute rest ; in treating all diseases this agent 
is the most important one. Kest is the fosterer of repair ; is 
necessary for the healthy action of every organ ; and the 
means instituted by nature to secure quiescence and recupera- 
tion of the various viscera of the body. True, relaxation and 
due exercise of mind and body, in alternation, promote and 
perpetuate health. When the forces are expended in useful 
pursuits, rest is the one therapeutic agent to restore energy 
for resuming action in vigorous health. 

In all periods of life, from infancy to decadence, intellectual 
vigor, moral courage and physical endurance render regular 
rest and refreshing sleep indispensable. Conspicuous among 
natural therapeutics are pure air and water, wholesome, nour- 
ishing food, proper protection and favorable surroundings. 
Without these other therapeutic means are useless. This 
should be kept in mind. In early practice the average physi- 
cian seeks new or vaunted remedies, and puts those in requisi- 
tion in abundance. Later experience and observation dispel 
this delusion. Eminent and experienced physicians usually 
settle upon comparatively few therapeutic agents, to them 
well known to be efficient in their action, to fulfill the various 
indications in treating disease. The cardinal rule is: Never 
severely impress the system, nor employ remedies which can 
injure it. Support the vital forces through natural therapeu- 
tics, rendering whatever auxiliary aid may be afforded by the 
use of drugs, employing few and simple remedies— only those 
whose nature and known action give good results. Investiga- 
tion for new remedies and new uses of old ones are commend- 
ble and should be encouraged. 



INDEX. 



Page 

Anatomical characters 16 

Atrophy '. 18 

A typhoid ulcer 156 

Anseniia — poverty of the blood... 195 

Acute yellow atrophy 264 

Albuminoid liver 267 

Abdominal aneurism 306 

Asthma 329 

Angina pectoris 355 

Acute pericarditis 364 

Acute myocarditis 368 

Atrophy of the heart 372 

Arteritis 388 

Apoplexy 403 

Aphasia 408 

Anaesthesia cutis 462 

Army itch 464 

Abscess of the lung 325 

Abscess of the liver 257 

Abscess of the brain 402 

Aphonia 334 

Addison's disease 201 

Aphthae 203 

Abscess, retropharyngeal 209 

Acne — A. simplex, A. rosacea 455 

Ascites 475 

Anasarca 474 

Ascarus lumbricoides 482 

Blood-poisoning 197 

Bloodvessels, diseases of, 388 

Bowel hemorrhage — melaena 235 

Bright's disease 311 

Brain, diseases of, 396 

Bronchitis 327 

Bronchial dilatation 332 



Page. 

Bullae — pemphigus 447 

Bilharzia haematobia 482 

Black death 486 

Causation of disease — etiology 9 

Congestion — hyperaemia 33 

Classification of diseases 75 

Clinical investigation of diseases 88 

Catalepsy 418 

Contagion, origin and nature of... 77 

Convulsions , 419 

Chorea— St. Vitus' dance 420 

Calcification 58 

Colloid degeneration 62 

Chronic articular rheumatism 177 

Cancrum oris — white mouth 204 

Cancer of the stomach 214 

Cancer of the duodenum, etc 214 

Congestion of the fiver 255 

Chronic diseases of the liver 266 

Cancerous and other growths of 

the liver .273 

Cirrhosis of the liver 275 

Congestion of the spleen 294 

Certain rare cardiac diseases 383 

Chloasma versicolor 453 

Clavus — corn 454 

Condylomata 454 

Chloasma versicolor 457 

Cerebro — spinal fever 141 

Cholera — epidemic 161 

Constitutional syphilis 189 

Chronic gastritis 212 

Colic, gouty, bilious, lead, etc 221 

Constipation 229 

Cholera morbus 227 



498 



INDEX. 



Page. 

Cholera infantum , 236 

Csecurn, diseases of, 243 

Cirrhosis of the liver 275 

Cystitis 317 

Collapse of the lung 327 

Croup , 336 

Consumption 340 

Cancer of the lungs 350 

Cyanosis — blue disease ..385 

Dropsy — hydropsy 37 

Dropsical diseases 474 

Degenerations 54 

Disinfection 85 

Diphtheria 107 

Diseases of digestive organs....... .202 

Dyspepsia — indigestion 215 

Diarrhoea 232 

Dysentery — bloody-flux 238 

Diseases of the liver, etc 245 

Diseases of the gall-bladder 280 

Diseases of the spleen 292 

Diseases of the pancreas 302 

Disease of suprarenal capsules 304 

Diseases of the urinary organs. .309 

Diabetes mellitus — glycosuria 315 

Diseases of respiratory organs 319 

Diseases of circulatory organs 355 

Diseases of bloodvessels 388 

Diseases of the brain and nerves.. 396 

Delirium tremens 432 

Diseases of the skin 440 

Dengue — break-bone fever 122 

Dietetic treatment 29 

Diathesis 169 

Dropsical affections 474 

Distoma hepaticum 481 

Distoma ophthalmobium 481 

Etiology 9 

Epidemics 82 

Epidemic, cholera 161 

Embolism 199 

Enteritis 217 

Endocarditis ....366 

Enlargement of the heart 371 

Epilepsy 416 

Emphysema of the lung 327 

Encephalitis 396 



Page. 

Eczema 445 

Ecthyma 449 

Elephantiasis Ara bum 455 

Entozoa 478 

Exanthematous inflammation. . . .441 

Elephantiasis Grcecorum 458 

Ephelis lentigo— sunburn 452 

Fatty degeneration 55 

Fatty infiltration 57 

Fibroid degeneration 60 

Fever — pyrexia 64 

Fatty liver— hepar adiposum 266 

Fatty degeneration of the heart... 373 

Favus, porrigo, tinea favosa 464 

Fever, types of, 67 

Filaria medinensis '. 485 

j Gonorrhceal rheumatism 181 

Cout — podagra 183 

Gastritis, acute 209 

Gastritis, chronic 212 

Gallstones— biliary calculi 282 

General diagnosis of chronic dis- 
eases of the liver 285 

General diagnosis of chronic car- 
diac diseases 375 

Guinea- worm 485 

Hypertrophy 17 

Hygienic treatment 30 

Hypersemia— congestion 33 

Hemorrhage 39 

Hooping-cough — pertussis 119 

Hepatalgia...., 247 

Hydatid tumor of the liver 268 

Hypertrophy — leucocythsemia....296 
Haemoptysis — -pulmonary hem- 
orrhage 352 

Hydrocephalus 400 

Hydrophobia — rabies 423 

Hemicrania — sick-headache 427 

Hysteria 434 

Hypochondriasis 439 

Herpes 446 

Herpes zoster 447 

Herpes circinatus 447 

Hypertrophia 453 

Hemorrhagise — purpura 460 

Hemorrhages 468 



INDEX. 



499 



Page. 

Haemateniesis 472 

Hematuria 472 

Hypodermic medication 493 

Introduction 5 

Induration 20 

Inflammation 41 

Individual diseases 93 

Influenza — epidemic catarrh 121 

Intermittent fever 123 

Induration of pylorus 214 

Icterus— jaundice 247 

Inflammation of the bile-ducts... 261 

Inflammation of the brain 396 

Inflammation of the spinal mar- 

row 403 

Intercostal neuralgia 428 

Impetigo .' 449 

Icthyosis — fish-skin disease 451 

Intestinal hemorrhage 473 

Intestinal worms 478 

Inhalation and atomization 490 

Jaundice — Icterus 247 

Keloid, kellis, kelois, cheloid 

sclerema 459 

Lardaceous disease 62 

Low types of fever...-. 68 

Lardaceous or waxy liver 267 

Laryngitis 332 

Laryngoscope 333 

Laryngismus stridulus 335 

Locomotor ataxia — Duchenne's 

disease 416 

Lepra — leprosy 450 

Leprosy (lepar Hebrseorum) 451 

Lupus, L. exedens and non-exe- 

dens 457 

Lichen, L. simplex, L. tropicus... 443 

Lichen agrius 444 

Mineral or calcareous degenera- 
tion 58 

Mucoid degeneration 61 

Measles — morbilli 117 

Mumps — parotitis, etc 118 

Malarial fever 123 

Muscular and tendinous rheuma- 
tism — myalgia 178 

Melasma supra-renalis 201 



Page. 

Melaena — intestinal hemorrhage..235 

Myocarditis 368 

Modes of sudden death in heart 

disease 374 

Malformations of the heart and 

great vessels 385 

Mediastinal tumors 394 

Migraine or megrim — sick-head- 
ache 427 

Maculae — decolorations 452 

Molluscum, acute, 456 

Molluscum, chronic, 457 

Nutmeg liver 256 

Nephritis 310 

Neuralgia 424 

Naevus (mole, mother mark) 453 

Neuroses 461 

Nernatoid or round worms 482 

Natural therapeutics 495 

Obstruction of the bowels 226 

Other morbid conditions of the 

spleen 298 

CEdema 474 

Ovarian dropsy 476 

Oxyuris vermicularis 483 

Preface to second edition 3 

Petrification 58 

Pigmentary degeneration 60 

Prevention and limitation of epi- 
demics 86 

Pernicious fever 134 

Pyaemia — blood-poisoning 197 

Pharyngitis 208 

Peritonitis 219 

Perihepatitis 261 

Pneumonia 319 

Pleurisy 322 

Pulmonary gangrene 326 

Pleurodynia — intercostal . rheu- 
matism 340 

Phthisis pulmonalis 340 

Palpitation 360 

Paralysis 408 

Prosopalgia — neuralgia of the 

fifth nerve 420 

Papulae 143 

Pemphigus 447 



500 



INDEX, 



Page. 

Pustulse ..448 

Psoriasis, P. vulgaris, P. gyrata, 

etc 450 

Pityriasis — dandruff., 451 

Prurigo and prurigo senilis 461 

Parasitica 462 

Plica Polonica 467 

Pulmonary apoplexy 471 

Pestis bubonica or bubo plague.. .486 

Rules for the practitioner 31 

Remittent fever 128 

Relapsing fever — famine fever.... 148 

Rheumatism 169 

Rheumatic fever 171 

Rheumatoid arthritis — deform- 
ans 181 

Rickets — rachitis 194 

Removal of the spleen 299 

Rhinoscopy 334 

Rare formations in the lungs 352 

Rupia 448 

Ring-worm 466 

Roseola 443 

Synopsis of contents 1 

Special causes of disease 15 

Softening 20 

Symptomatology — semeiology ... 22 

Scarlatina — scarlet fever 100 

Scurvy — scorbutus 187 

Scrofula — scrof u losis 191 

Syphilization 190 

Spotted fever 141 

Syphilis — infantile 190 

Stomatitis 202 

Stricture of the oesophagus 209 

Syphilitic disease of the liver 279 

Splenitis — hemorrhagic infarc- 
tion 295 

Syncope — fainting 358 

Strophulus — red gum 444 

Softening of the brain 401 

Sciatica — bip.gout 429 

Squamse 450 

Spedalsked 451 



Page, 

Scabies 463 

Sycosis (mentagra) 465 

Syphilis — syphilida 467 

Scald head 466 

Sclerostoma duodenale 485 

The use of the thermometer 89 

Typho-malarial fever 137 

Typhus fever, ship fever, etc 149 

Typhoid fever, enteric fever, etc.. 153 

Thrush— muguet 204 

Tonsillitis — quinsy 207 

Tuberculosis of the liver 279 

Thyro-cardiac disorder 375 

Thoracic aneurisms 391 

Tubercular meningitis 399 

Tetanus 422 

Trematode worms 481 

Tic douloureux— brow ague 426 

Tubercula 455 

Tinea circinatus 466 

Tinea decalvans 466 

Tape worm...... 479 

Types of fever 67 

Tetrastoma renale 482 

Trichocephalus dispar 483 

Trichina spiralis 484 

The plague 486 

Ursemia 309 

Uterine hemorrhage 473 

Ulcerations of Peyer glands 154 

Urticaria— nettle rash 442 

Variola — small-pox 93 

Vaccination 97 

Varicella— chicken-pox 99 

Valvular disease 369 

Vesiculse 445 

Vitiligo — veal-skin 452 

Veryuca — wart 454 

Vicarious hemorrhage 473 

What we must know of a patient 22 

White seat worms 483 

Yellow fever 137 

Yellow atrophy 264 

Zvmotic diseases 93 



3 47 7 



